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   Current UPMC employees must apply in HR Direct

Director, LTSS Clinical Operations

  • Job ID: 660728464
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: UPMC Health Plan
  • Department: CHC Service Coordination
  • Location: , Philadelphia PA
  • Union Position: No
  • Salary Range: $0 / hour

Description

Purpose:
Manage the direction of activities related to the care management and service coordination of UPMC Community HealthChoices, SNP and Medicare membership with the aim of promoting independent living and avoiding skilled and or custodial, institution based care. Provides day-to-day clinical operational oversight for staff caring for members who need care management and supportive services to transition to the home setting from an institution based setting. Oversees the development and ongoing clinical programs tailored to meet the needs of geriatric and disabled members. Establishes effective relationships with staff, members, caregivers and vendors to optimize the outcomes of members and promote the optimal quality of independent living consistent with the members' expectations.

Responsibilities:

  • Manage oversight, management and documentation of medical management quality work plan and annual program evaluation related to the technology utilized in the medical management department.
  • Develop, monitor and manage budgets related to clinical operations, system support and implementation projects.
  • Analyze, evaluate and present information concerning factors, such as business situations, production capabilities and design and development of system processes to all customer levels within the organization.
  • Manage all aspects of geriatric services and care management service delivery for geriatric and disabled members needing assistance to optimize their independent living status.
  • Manage production, quality audit and management of reporting produced from the medical management department for external reviews for Health Management, i.e. DHS and Medicare reviews.
  • Proactively identify risks and work with management staff to mitigate risk and implement corrective action plans as necessary.
  • Direct the liaison functions between the UPMC Health System and other network providers to ensure successful service coordination and utilization management processes.
  • Develop and oversee coordinated approaches to Medicare and Medicaid delivery to foster integration and improved member experiences including case management, utilization management of post-acute services, and holistic member engagement.
  • Direct all processes implementation activities related to case management of high risk members requiring short term, institution based care transitioning to home based care.
  • Work in close collaboration with the Community HealthChoices, Medicare, and D-SNP product teams.
  • Communicate effectively in individual and group situations to ensure optimal implementation, and processes, interface with both internal and external providers, regulatory and compliance auditors, staff and members.
  • Analyze and trend data to identify area of opportunity and implement process improvements.
  • Partner with Information Systems management personnel to evaluate technology solutions, custom development and/or system implementation for internal and external customers.
  • Establish and oversee geriatric services training in accordance with the care model across internal and external staff.
  • Ensure operational performance within the clinical operations support area through analysis, critical decision making and implementation of automated solutions.
  • Work with Senior Management to achieve efficiencies across integration of projects.
  • Represent clinical services on internal and external forums and committees, as requested.
  • Continuously evaluate and manage documentation of customer needs and all aspects of business processes to assure systematic processes are being utilized to capacity to optimize system efficiencies.
  • Develop and maintain work plans which include time, resource allocation, testing and implementation of new business, medical management programs or technology.
  • Develop tactical strategic plans for business units to optimize efficiency and achieve corporate business objectives.

 

Qualifications

  • Bachelor's degree required, Master's preferred with 7 years' experience managing care coordination of geriatric and or disabled members and post acute and home based care. RN Preferred.
  • 5 years of experience in management and in health care insurance or health care industry with regulatory, compliance and information system knowledge.
  • Experience with Medicare/Medicaid integration and Medicaid managed long-term services and supports preferred.
  • Proficient knowledge in MS Office and PC skills required.
  • Ability to demonstrate excellent organizational, interpersonal and communication skills.
  • Strong project management, problem-solving, organizational, and communication skills (oral and written) are required.
  • Ability to perform planning for large initiatives/projects, as well as manage all tasks required to meet departmental and business needs within budget and targeted deadlines.
  • Strong leadership skills and independent decision making ability.


Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct