Dual Special Needs Clinical Programs Associate Director

Job Details

Job Location
Main Office - Santa Barbara, CA

Position Type
Full Time

Education Level
Bachelor's Degree

Job Category
Medical Management

Description

Central Coast Salary Range:$150,552 - $225,828 annually

Job Summary

Candidates for this position must reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties) or be willing to relocate to the area upon hire. As a community-facing role, a local presence is essential to effectively engage with and serve our community. Please note that relocation assistance may be available.

The D-SNP Clinical Program Associate Director is a highly skilled operational leader with extensive experience in managing and executing clinical program operations. This role is responsible for the performance and delivery of multiple Care Management programs, including D-SNP, High Risk, Transitions of Care, Community Supports, Palliative Care, Dementia Care, and other Utilization Management programs. The D-SNP Clinical Program Associate Director promotes cross-functional collaboration, leads and develops teams, and plays an active role in audits, as well as forecasting and advancing clinical program improvements.

The D-SNP Clinical Program Associate Director oversees both the Care Management and Utilization Management departments for members enrolled in the D-SNP program, covering both Medicare and Medi-Cal Lines of Business (Duals). The D-SNP program aims to enhance the member experience, improve access to medically appropriate care, and streamline care and benefit coordination.

Duties and Responsibilities

• Oversee the implementation and management of Care Management and Utilization Management programs for D-SNP (Dual Eligible Special Needs Plan) populations, ensuring alignment with organizational goals and regulatory standards.
• Lead cross-functional teams to integrate and coordinate Care Management and Utilization Management programs, focusing on enhancing the member experience and improving health outcomes.
• Ensure all model of care requirements are met for D-SNP members, including completing Health Risk Assessments (HRAs), coordinating face-to-face visits, developing individualized care plans, and facilitating Intra-Disciplinary Care Team (IDT) meetings.
• Create and maintain program documentation, update policies, procedures, and guidelines for both Care Management and Utilization Management programs to ensure compliance with CMS, state, and federal regulations, and best practices.
• Oversee case reviews, ensuring care plans are appropriate, cost-effective, and tailored to meet the unique needs of each member while reducing unnecessary utilization. Ensure care plans are shared with Primary Care Providers and the IDCT Team.
• Collaborate with external stakeholders, including healthcare providers, vendors, and community organizations, to enhance care delivery, improve access to services, and increase member engagement.
• Serve as the D-SNP Department liaison, facilitating communication between internal stakeholders, providers, and the community, and ensuring timely resolution of any issues.
• Monitor staff productivity, conduct regular audits of Care Management and Utilization Management processes, identify opportunities for improvement, ensure compliance, and address any deficiencies. Participate in internal and external audits.
• Assist in developing and maintaining key performance indicators (KPIs) and metrics for both Care Management and Utilization Management programs to track success, enhance performance, and report progress to leadership.
• Lead the hiring, training, development, and performance management of Care Management and Utilization Management teams, ensuring staff are well-equipped to provide effective, compassionate care and meet program goals.
• Lead special assignments, focused projects, and strategic initiatives as directed, ensuring timely completion and successful outcomes.
• Foster collaboration between clinical and operational teams to streamline workflows, improve care coordination, and reduce care fragmentation for members.
• Address and resolve any issues or barriers affecting program performance, providing solutions that align with organizational goals and improve member outcomes.
• Contribute to special assignments, audits, and targeted projects, while also performing other related duties as needed to support program objectives and organizational goals.

Qualifications

Knowledge/Skills/Abilities

• Ability to collaborate effectively with both internal and external stakeholders, including various programs within the Health Services department, such as Utilization Management, Care Management, Behavioral Health, and Pharmacy.
• Knowledge of clinical program design, implementation, and management, with a focus on Care Management (CM) and Utilization Management (UM) for D-SNP, dual-eligible, Medicare, and Medi-Cal populations.
• Skilled in fostering collaboration across clinical, operational, and administrative teams to drive program success and improve member outcomes.
• Proven experience in managing, mentoring, and developing clinical teams, with a focus on performance improvement and achieving program objectives.
• Familiarity with clinical management software, electronic health records (EHR), and data reporting tools to support program monitoring and reporting.
• Ability to work effectively with diverse populations, understanding and addressing cultural differences in care delivery and member engagement.
• Ability to excel in a fast-paced, dynamic healthcare environment, adjusting strategies and approaches as needed to meet evolving needs and priorities.
• Expertise in managing multiple projects simultaneously, with a strong ability to prioritize tasks, meet deadlines, and maintain high-quality standards.
• In-depth understanding of healthcare regulations, including CMS, state, and federal requirements for Medicare and Medi-Cal programs, ensuring compliance with policies and procedures.
• Excellent verbal and written communication skills, with the ability to present complex clinical concepts clearly to both clinical and non-clinical stakeholders.
• Strong analytical skills, with the ability to identify challenges within clinical programs and develop effective solutions to improve processes and outcomes.
• Proficient in Microsoft Word, Excel, Outlook, and PowerPoint.

Education and Experience

Required:

• Bachelor's degree in a related field.
• Active and unrestricted California Registered Nurse certification.
• Five (5) years of experience in medical management within a managed care setting, including at least two (2) years in a supervisory role or higher, which may substitute for a bachelor's degree.
• Experience with Medicare and Medi-Cal Lines of Business.

Preferred:

• Master's degree in a related field, such as Nursing, Business, Healthcare, Health Administration, or similar.
• Certification in CCM, ACM.