• Manager, Clinical Operations MLTSS

    Job Locations US-VA-Glen Allen
    Job ID
    2018-4627
  • Overview

    Responsible for leadership and management of Clinical Review staff and operations staff who perform member level of care changes and LOCERI reviews. Responsible for daily clinical decisions, process improvement, staff development, and compliance with Virginia Premier policies and procedures. Also responsible for identifying and delivering clinical process improvements for the VPHP MLTSS line of business

    Responsibilities

    • Oversees Supervisors of Clinical Review staff and other operations staff under MLTSS Line of Business according to Virginia Premier policy and procedures to assure that clinical reviews, level of care updates, and LOCERI reviews are accurate, consistent, and performed in a timely manner for Long Term Support Services
    • Assists with the development of clinical review and operational staff onboarding and training programs
    • Coaches staff and supports healthy team dynamics
    • Serves in an advisory capacity for problem solving, reviewing reports being sent to internal and external customers, reviewing problematic cases, and monitor utilization management activities
    • Serves in an advisory capacity for problem solving, reviewing metrics related to timeliness of reviews
    • Maintains resources, keeping information up-to-date
    • Assists in the ongoing development of programs and medical management projects to enhance/expand the medical management department
    • Maintains confidentiality of patient information, and VPHP proprietary operational information
    • Monitors business processes and manages VPHP MLTSS operational processes as defined by the state contract and VPHP MLTSS model of care
    • Ensure requirements for auditing clinical review decisions, documentation and quality are being met
    • Assists Director of Health Service with ongoing Quality Improvement Program by assisting with various quality review tasks such as collecting and analyzing data as outlined in the program
    • Assists in the ongoing development of programs and medical management projects to enhance/expand the medical management department
    • Maintains confidentiality of patient information, and Virginia Premier proprietary operational information
    • Maintains current knowledge of Virginia Premier policies and procedures
    • Participates in continuing education activities as appropriate
    • Participates in community programs (which may occur outside of normal business hours)
    • This position provides services and demonstrates the knowledge and ability to meet the specific needs of all age groups
    • Other duties as assigned

    Qualifications

    REQUIREMENTS

    • Registered Nurse licensed to practice nursing in Virginia
    • Bachelor’s degree in nursing or health related field preferred
    • Utilization Management experience
    • Management experience

     

    SPECIAL KNOWLEDGE AND/OR SKILLS

    • Excellent problem solving skills
    • Knowledge of community resources and vendor options, and experience in making appropriate referrals
    • Ability to negotiate with providers and vendors
    • Demonstrates excellent verbal and written communications
    • Demonstrates working knowledge of computers and word processing programs
    • Ability to build and support successful work teams
    • Possess knowledge of ICD-9 and CPT4 coding
    • Knowledge of Six Sigma Lean methodology or other Performance Improvement methodology

    WORK BACKGROUND/EXPERIENCE

    • Minimum of 3 years utilization management experience, preferably in a managed care environment
    • Minimum of 1 year Management experience
    • Experience in clinical nursing
    • Experience working with low income disadvantaged populations
    • Knowledge of evidence of Home and Community Based Waivers preferred

    PHYSICAL REQUIREMENTS

    • Physical health sufficient to meet the ergonomic standards and demands of the position

    About Us

    Virginia Premier is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 

     

    We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  

     

    All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

     

    Our mission is to inspire healthy living within the communities we serve!

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