SUMMARY: The Manager, Clinical Programs Oversight is responsible for management and oversight Medicare Advantage programs and initiatives for Senior Health Services. This position provides effective and efficient solutions to complex business problems and responsibilities include maintaining effective relationships within and across teams, key vendors, and clients to ensure that the issues and needs of Medicare Advantage are represented and prioritized in all clinical programs. This role is also responsible for strategizing, innovating, analyzing, planning, organizing, budgeting, reporting, and other functions that are required to maintain and operate an efficient and effective team. RESPONSIBILITIES/TASKS: * Provides support and oversight Medicare Advantage medical management services including utilization management (UM) and grievance and appeal (G&A) * Oversight of key metrics, including quality, productivity, and compliance * Supports successful execution of Medicare Advantage Programs and initiatives in accordance with CMS requirements * Participates in planning, organizing, and directing activities of Medical Management including, but not limited to, planning, training, motivation, staff development, staff selection, and communication. * Provides or orchestrates the provision of subject matter expertise and support related to medical management (UM and G&A) * Maintains and promotes quality relationships with internal and external customers. * Participates in analyzing statistics and prepares activity related reports, staffing needs, and inventories and monitors workflows within the G&A and UM areas as assigned * Leads and participates in workgroups and task forces in order to complete special assignments and projects. * Ensures the resolution of high priority inquiries- including issues of non-compliance with related vendors or programs * Recommends processes to control expenditures and promotes efficient use of resources. * Participates in development of annual departmental budget, monitors budget. * Responsible for balancing workload to optimize the effectiveness of the department. DIRECTION EXERCISED: Directly supervises exempt and non-exempt staff in accordance with company policies and applicable Federal and State Laws. Responsibilities include, but are not limited to, effectively interviewing, hiring, terminating, and training employees; planning, assigning, and directing work; appraising performance; rewarding and counseling employees; addressing complaints and resolving problems; supporting and encouraging the engagement process. This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required. EMPLOYMENT QUALIFICATIONS: EDUCATION: Bachelor's degree in Business Administration, Health Care Administration, Marketing, or a related field. Master's degree in a related field is preferred. Clinical background (e.g. RN) highly preferred. Relevant combination of education and experience may be considered in lieu of degree. Valid and unrestricted driver's license is required. Continuous learning, as defined by the Company's learning philosophy, is required. EXPERIENCE: Seven years of experience with progressive responsibility in a business environment with demonstrated technical knowledge that provides the necessary knowledge, skills, and abilities required. Three years supervisory or lead experience in business required. SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED: * Ability/willingness to develop, recommend and execute solutions to ad hoc issues and challenges that may arise. * Strong knowledge of Grievance and Appeals and Utilization Management processes and concepts. * Subject matter expertise in Medicare Advantage and medical management (i.e. Utilization Management, G&A,, etc.). * Ability and willingness to delegate, guide and oversee work of team on projects. * Excellent analytical, organizational, planning, verbal, and written communication skills required. * Proficient in work that involves analysis, organization, planning, presentation development, problem resolution, sales, strategy, and innovation. * Must be self-motivated, results-oriented and can work well under pressure. * Ability to effectively present information and respond to questions from internal and external contacts at all levels of the organization. * Ability to read, analyze, write, and develop communications (i.e. white papers, strategy decks, etc.) or reports as required by leadership. * Proficient in current industry standard PC applications and systems. * Extensive knowledge of operations. * Must demonstrate leadership ability and team building skills to effectively supervise professional and non-professional staff and interact with all levels of management. * Ability to work with and empower others on a collaborative basis to ensure success of unit team. * Ability to effectively exchange information, in verbal or written form, by sharing ideas, reporting facts and other information, responding to questions, and employing active listening techniques. * Ability to effectively present budgetary and/or cost information and respond to questions as appropriate. * Ability to establish workflows, manage multiple projects, and meet necessary deadlines. * Ability to maintain confidentiality. WORKING CONDITIONS: Work is performed in an office setting with no unusual hazards. Occasional travel is required. The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description. PAY RANGE: "Actual compensation decision relies on the consideration of internal equity, candidate's skills and professional experience, geographic location, market and other potential factors. It is not standard practice for an offer to be at or near the top of the range, and therefore a reasonable estimate for this role is between $88,600 and $148,500." We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an \"at will\" basis. Nothing herein is intended to create a contract. #LI-CH1
