Position Purpose: In conjunction with the Chief Medical Officer (CMO) and VP Clinical Programs, manage the implementation and administration of Clinical Program research and development. Oversee integration of internal operations needed to ensure compliance with clinical programs developed that are required under state contract, RFP, HEDIS, or other national standards.

 

• Work with CMO and VP, Clinical Programs with new programs designs.


• Research and facilitate implementation of new clinical programs for Health Plans and/or specialty companies to meet State contract, RFP, HEDIS, or other organizational needs.


• Coordinate cross-functional meetings with various areas to meet overall stakeholder expectations and company’s objectives for clinical programs.


• Coordinate and/or create policies, procedures, workflow, training materials, and reporting in accordance with corporate, state and federal, HEDIS or other requirements.


• Manage the research and implementation functions for Clinical Programs to ensure program integrity and compliance.


• Oversee the integrity of Clinical Programs developed including outcome reporting and the publications. Coordinate with Corporate departments and Health Plans to execute Clinical Programs.


• Examine and evaluate Clinical Program goals, measures, and outcomes against demographic, historical and geographic membership and/or provider data. Facilitate ongoing reporting needs to reflect clinical program outcomes.


• Serve as an interface between the corporate program unit and Health Plans. Interact with internal Corporate, Health Plan, and external medical society personnel to assist with development of clinical programs.


• Interact with organizations and State and Specialty Society points of contact as needed.


• May be required to travel.

Qualifications:

• Position is not remote. Located in Fresno, CA.


• Relocation may be available.

Highly desired:

• RN or LVN with Prior Authorization knowledge, strong concurrent review knowledge, familiar with UM & Interqual.

Education/Experience:

• Bachelor’s degree in Healthcare Administration, Nursing, related field or equivalent experience. 4+ years of program development and management experience. Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff. Managed care experience preferred.

License/Certification:

• LPN or RN license. Valid driver's license.