Director, Clinical Operations

Job not on LinkedIn

September 21

🍂 Massachusetts – Remote

Although this job is listed in Massachusetts, this company may be open to hiring remote in other states.

⏰ Full Time

🔴 Lead

🏥 Clinical Operations

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Mass Health

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Healthcare Insurance • SaaS

Mass Health is a company specializing in Remote Patient Monitoring (RPM) solutions designed to enhance patient care and streamline healthcare delivery. By leveraging advanced technology, Mass Health offers real-time monitoring, health analytics, and expert consultation services to improve patient outcomes, particularly for chronic conditions such as hypertension, diabetes, and heart disease. The company focuses on seamless integration with existing healthcare workflows, ensuring ease of use for healthcare providers and maintaining high standards of data security and compliance. Mass Health's innovative approach empowers healthcare practices to manage patient care more efficiently and effectively from a distance, transforming the landscape of digital healthcare.

2 - 10 employees

⚕️ Healthcare Insurance

☁️ SaaS

📋 Description

• Oversight of clinical functions including utilization management, care coordination, and integrated care processes • Report to the Chief Medical Officer and collaborate with CEO, VP of Operations, Chief Compliance Officer, Chief Financial Officer, and other senior leadership • Develop and implement clinical strategies aligned with organizational goals • Establish policies and procedures and ensure compliance with CMS and accreditation standards • Perform reviews of operations and delegated entity decisions to determine medical appropriateness of inpatient and outpatient care • Provide telephonic utilization review, continued stay reviews, and utilization management based on clinical guidelines • Ensure evidence-based referral management, inpatient concurrent review, and care management to promote efficiency and regulatory compliance • Provide utilization and cost data measured against regional and external benchmarks • Complete UM delegation responsibilities • Manage and oversee the Care Management team and align programs with organizational goals • Collaborate with Social Work care managers, medical directors, and provider staff to coordinate care across the continuum • Advocate for patient needs, negotiate for services, and develop patient-centered care plans • Assess patient medical, behavioral health, and social determinants needs and prioritize care • Assist senior leaders with program design and write policies and procedures meeting CMS and accreditation standards • Lead audit activities including CMS Program audits for Organizational Determinations, Appeals and Grievances, and accreditation efforts • Report quality of care issues identified during utilization review according to policy • Promote and oversee performance improvement activities and complete annual HEDIS requirements • Summarize and analyze data, prepare statistical reports, and present monthly utilization management and care management reports to Senior Management • Collaborate with Care Management, Population Health, and Quality leaders and provide mentorship to clinical teams • Reasonable accommodations may be provided to enable individuals with disabilities to perform the essential functions.

🎯 Requirements

• Bachelor’s degree in nursing or related field preferred • Master’s degree preferred • RN with current unrestricted Massachusetts License • Certification in Coding (CPC/CCS/etc.) or Utilization Management (CPUM/CPUR/CPHM) is a plus • Continuing education requirements are met through the renewal of licensure by the Massachusetts Public Health Department • 3-5 years of clinical experience in acute care settings (Med/Surg, ICU, Step-Down, ED/ER, OR) • 3-5 years of experience in Medicare Advantage health plans, managed care organizations, or similar settings • Experience in care management, utilization management, and quality improvement • Familiarity with MCG/Milliman/InterQual criteria for medical necessity and concurrent patient management • Experience in start-up environment with desire to build the organization’s sustainable and scalable clinical operations