Executive Director, Medicaid Clinical Health ServicesPrimary Location: Phoenix, AZ
Additional Locations: AZ-Phoenix Apply
The Executive Director facilitates the delivery of appropriate, cost-effective, and quality medical benefits for the Medicaid beneficiaries. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure appropriate utilization. Services and strategies are comprised of network management support, clinical coverage policies and programs, and medical payment policies.
Provides clinical leadership for the Aetna Medicaid segment Utilization Management division which includes direct leadership for utilization management activities and strategic leadership across clinical services.
- Define, develop, guide and implement all assigned clinical functions for the Medicaid Modernization program.
- Lead and drive clinical strategy and performance for Medicaid populations
- Drive the strategic agenda for clinical management supporting multiple markets for the Medicaid products.
- Partner with local market lead and MD management to analyze and support the utilization performance of all relevant markets.
- Provide strategic guidance to other market clinical teams in matrixed support functions, i.e. QM, CM
- Create strategic and tactical approaches to medical management that support relevant and value-based network strategies within the geographic markets.
- Meet all market utilization goals in both quality of care and cost of care
- Support and provide leadership accountability for NCQA accreditation and STARS results across the plans in a matrix environment
- Oversee and ensure compliance with all applicable Federal and State regulations relevant to the plans function.
- Lead a virtually integrated staff (including clinical and non-clinical members) within multiple geographic markets.
- Provide subject matter expertise to pursue market growth opportunities and support implementations
- 8-12 years of Managed experience, Medicaid highly preferred
- 6-9 years Planning, leading and organizing the resources of a team
- 6-9 years Ability to engage at all levels, including physicians, vendors, administrative leaders, clinical leaders and staff.
- 6-9 years Leading UM Committees/and or Clinical Review teams. Comprehensive experience using standardized clinical criteria (Milliman and/or InterQual for denials and authorization decisions, with attending escalation processes
- 6-9 years Analyzing, interpreting and presenting financial utilization data
- 6-9 years Patient care or health education in variety of settings
- 6-9 years Coaching, counseling and administering corrective action
- Bachelor's Health Administration, Management, Nursing, Social Work, or other Health related field Required
- Master's Health Administration, Management, Nursing, Social Work, or Business Preferred Or equivalent education/experience
- Licensures and Certifications
- Registered Nurse - State Licensure - RN Required
- Other Lean Certification Preferred
- Other Six Sigma Black Belt Preferred
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