Director of Population Health and Clinical Excellence - Full-time / Part-time

The Director of Population Health and Clinical Excellence (DPHCE)provides strategic leadership and is accountable for all clinical programs for all products and membership served by the health plan to ensure contractual compliance and achievement of clinical and utilization management goals.  This statewide director serves as the primary point of contact and is accountable for all aspects of the population health program to include health plan clinical performance in affordability and the clinical integration and implementation and development of an integrated services model..  Because of the unique structure and alignment of clinical programs both within the State of Tennessee's Medicaid program called TennCare , and within United Healthcare, the (DPHCE role requires a high degree of coordination with external and internal business partners, including, but not limited to the UHC-Clinical Services inpatient and Intake/Prior Authorizations, Appeals and Grievance, Quality, Optum case and disease management, Healthy First Steps, Neonatal, Behavioral Health, and other clinical specialty, external vendors, and  national programs.

1. Leads, coaches/develops, trains (in conjunction with clinical learning team) and supports health plan based clinical teams. Ensures effective, compliant, clinical program delivery, monitors performance and clinical outcomes.


2. Contributes to the development and execution of overall health plan strategies, Winning Priorities Key Initiatives through active participation in Health Plan Sr Leadership/Operations meetings and health plan functional meetings


3. Fosters and promotes two-way communication and information sharing necessary for successful clinical program implementation. Is the Primary liaison to clinical business partners both internal and external for member/clinical issues such as Optum HFS/ NICU, Optum Care Plus,  Optum Care Solutions which includes Case Management and  HARC, Prior Authorization, Intake, UBH, Appeals & Pharmacy Departments- point of contact for reporting, troubleshooting, case reviews, member complaints and issues requiring local health plan support.


4. Identifies network gaps and access issues and participates in local market Network Management Governance meetings to ensure issues are addressed


5. In conjunction with the Health Plan medical director, ensures regularly scheduled interdisciplinary meetingsincluding the regional community based care teams, and processes are in place to address member and provider issues/needs.


6. Leads in collaboration with UHCCS and Optum business partners in audits such as the External Review Quality Organization Audits for clinical programs which may include developing/owning program material binders and responses.


7. Serves on and chairs  the Health Plan Committee on Servcies . Reports clinical metrics and reports as neded into the QMC and PAC meetings. Develops & maintains UM/CM/DM annual work plan, program description, and program evaluations


8. Is a  key clinical leader at the health plan for NCQA accreditation preparation and surveys. Works collaboratively with Quality Leader and Medical Director, leveraging National Best Practices/Polices/Procedures, shared services and benefits partners to prepare the documentation and readiness for NCQA accreditation of the local health plan.


9. Develops strategies internally and with business partners for clinical management during high volume provider termination, new membership growth/expansion–ensuring member continuity of care and transition of care needs are met according to the RFP response/contractual requirements   


10. Ensures timely communication of any new contractual requirements, audit findings or business expansion opportunities to National Medical Management and Shared Services Partners to ensure appropriate planning and implementation (including resource needs, timelines, IT needs, etc).


11. Implements team initiatives associated with making United Healthcare a great place to work, including embracing Our United Culture and sustaining a highly-engaged work force as measured by the annual Vital Signs Survey.  


12. Works in partnership with National Medical Management Leadership to develop clinical staffing, clinical model, IT changes/requests to ensure funding, timely approval and execution.


13. Works with other health plan leaders to escalate clinical performance issues to National Medical Management Leadership as needed if unable to affect change locally.

Compliance/Adherence

• Ensures adherence to state contracts for all population health and medical management/clinical requirements,  and holds business partners/shared services teams accountable for compliance. Has monitoring and controls in place to regulatory measure and monitor performance.


• Identifies and addresses any contractual risks early and implements a performance improvement plan with population health patners including CM/DM and UM partners to become contractually compliant. Communicates timely, any changes in clinical contractual requirements, Clinical CAPs, sanctions or fines to National Med Mgt Leaders/Business Partners and ensures changes are made to business processes to adhere to changes requirements


• Leads the development and implementation with business partners, of health plan specific policies & SOPs to support UM/care management strategies and contractual requirements, CM interventions, and administrative functions and ensures regular review and maintenance processes are in place.  Utilizes national policies, procedures, SOPs as the basis for developing or adapting for state specific requirements. Leads and ensures adoption and delivery of nationally approved policies, procedures, guidelines and standards for health plan based clinical staff and (and business partners). Conducts local clinical documentation reviews and monitoring to ensure compliance with requirements.


• Attends Clinical Governance Leadership meetings as needed- monitor reports for outcomes and alignment with health plan targets and regulatory compliance


• Promotes ease of use of an Interdisciplinary Team review process so it is used by clinical staff to address member complex issues, conduct secondary review process for LTSS and/or HCBS care plans and address barriers to service delivery and ability of member to achieve goals.


• Works in partnership with local compliance to support Medicaid and Medicare (if appropriate) Fair Hearing and SAP Process.


• Knowledge of each line of business (Medicaid, Medicare) and cohort operation results and develops improvement plans as appropriate

 Customer Relationships

• Actively participates in State and Provider meetings in collaboration with the Health plan leadership, CMO.


• Actively participates in community outreach and networking activities to develop support and community infrastructure to meet member needs, promote membership growth and retention.


• Works with Health Plan Medical Director to establish strong provider relationships, promote/support the development of ACOS, PCMH initiatives and other provider engagement strategies.


• Fosters/supports social responsibility activities within the Health Plan/UHG and local community


• Actively embraces United Culture and Values in working with both internal and external customers/partners.


• Participates in member advisory boards as appropriate for all lines of business i.e. Medicaid , LTSS Dual SNP. 

Healthcare Transformation , Affordability, and Clinical Excellence

• Works side by side with the regional medical and health plan medical directors, this position is the owner of the state's clinical performance of the integrated service model.  They are accountable for leveraging community resources and transforming the network to improve clinical outcomes for member in the TennCare program including Medicaid and dual SNP populations. Our program requires ongoing integration of physical, behavioral, and Long Tern Support Services.

• Drawing on innovative statewide and national programs, the  Director, provides management oversight and implementation support to incorporate applicable best practices with proven outcomes. They work with  regional executive  directors and are jointly  responsible for developing and driving a local flavor of the established TennCare population health model.  This position is created to manage cross functional teams that impact clinical results, as well as to deploy the pre-defined population health clinical models through a localized plan to ensure clinical excellence. Data driven quality improvement of regional performance is expected.

• The director develops and is accountable for multiple integrated service models and population health programs which bring our membership needed services for physical, behavioral, and social services. Clinical models include accountable care programs (shared savings arrangements, novel value based payment models such as episodes of care, Patient Centered Medical Homes, Health Homes for members with complex illness including mental health illness and substance abuse, and Accountable Care Organizations (ACOs).  Population Health programs include Neighborhood Connections (outreach, navigation) ,Optum high risk and transitional care, Optum Care Plus nurse practitioner home visits, Healthy First Steps maternity medical homes, , and the Accountable Care Community. This person leads UnitedHealthcare to the next level to meet the demand of the State of Tennessee customer and the ever changing healthcare industry.

•  The position entails regular interaction with key regional provider leadership to offer direct feedback to programmatic strategy and improvement.  They will provide strategic recommendations on member and provider incentive program design, engagement strategy, and provider network optimization. Innovative solutions for of emerging program needs are expected which allow early detection and development of creative solutions. 


 

Careers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to do your life's best work.SM

Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability status.




UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.