Clinical Director, Health Plan Operations RN, Michigan

McLaren Health Care is a fully integrated health network committed to quality, evidence-based patient care with locations in Michigan and Indiana. The McLaren system includes 13 hospitals in Michigan, ambulatory surgery centers, imaging centers, a primary and specialty care physician network, commercial and Medicaid HMOs, home health, infusion and hospice providers, pharmacy services, a clinical laboratory network and a wholly owned medical malpractice insurance company. McLaren operates Michigan’s largest network of cancer centers and providers, anchored by the Karmanos Cancer Institute, one of only 53 National Cancer Institute-designated comprehensive cancer centers in the U.S.

Clinical Director, Health Plan Operations RN, Michigan

McLaren Health Plan (MHP) is a company with a culture of high performance and a mission to help people live healthier and more satisfying lives. We are looking for a Director, Medical Management to join in leading the organization forward.

MHP is a Managed Care Organization dedicated to meeting the health care needs of each member.MHP offers multiple product lines, including individual and family plans, and Medicaid and Medicare plans to Michigan residents for every stage of life.McLaren Health Plan is accredited by the National Committee for Quality Assurance (NCQA).

MHP values the talents and abilities of all our employees and seeks to foster an open, cooperative and dynamic environment in which employees and the health plan can thrive. As an employee of MHP, you will be a part of a dynamic organization that considers all our employees as leaders in driving the organization forward and delivering quality service to all our members.

Provides overall management and direction for the assigned Plan's health services and medical management activities to meet organizational goals. Assumes responsibility for the clinical administrative aspects of utilization review and case management. Integrates medical management processes with all departments within the Plan with a focus on ongoing communication. Directs Medical Management processes to be appropriate; compliant with NCQA standards and regulatory agencies and within budget. Develops and implements departmental policies and procedures as well as documentation of the case management and utilization management processes. Responsible to collaborate in the delivery of the Quality Improvement Performance Plan (QPIP) to facilitate that quality standards are met, with a focus on all assigned NCQA standards. Responsible for the selection, training of health care staff, development and implementation of policies and procedures for inpatient, outpatient and ambulatory utilization that result in delivery of medical care in a cost efficient and quality manner. Assists where necessary or through project management those business ventures undertaken by the Company to ensure its profitable future.

This is a hybrid position with requirements to come onsite as scheduled, Flint, MI.

Qualifications:

Required:

• Bachelor's Degree in Nursing, health care or business-related field
• Valid RN License in state doing business in
• Ten (10) years' experience in a progressively more responsible leadership role in managed care leading utilization, case and/or quality management with demonstrated experience involving clinical and quality analysis and direct interaction with health care providers with at least four years' experience in a management role with direct reports, leading or assisting in all phases of effective supervisions (i.e. recruitment, performance management, training)
• Three (3) years' clinical experience in a licensed field

Preferred:

• Professional certification in related areas (i.e. Case Management, HEDIS)
• Fifteen (15) years' experience and knowledge of Managed Care functions (e.g. medical delivery, regulatory compliance, HEDIS, NCQA)
• Affiliation with a Professional Organization

Additional Information

• Schedule: Full-time
• Requisition ID: 25007356
• Daily Work Times: 8:00 am - 5:00 pm
• On Call: No

McLaren Health Care is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identification, age, sex, marital status, national origin, disability, genetic information, height or weight, protected veteran or other classification protected by law.