SCOPE OF ROLE

The Director, Clinical Performance is responsible for the management of clinical capabilities related to Delegated Utilization Management and Delegated Care Management across multiple health plan clients in the California Medi-Cal, Medicaid delegated services markets. The role is responsible for overseeing day to day clinical operations.

This is a work from home position based in California or the Pacific Time Zone.

 ROLE RESPONSIBILITIES

• Ensure clinical review criteria (e.g., evidence-based guidelines) are applied consistently in authorization and review processes.
• Support and engage in daily UM workflows, including case review processes, turnaround time management, and staffing models, while helping maintain performance standards for authorizations, denials, and appeals.
• Participate in internal and health plan audits, assist in maintaining UM policies and procedures, and support accurate medical necessity determinations in accordance with clinical guidelines.
• Partner with medical directors to resolve complex cases and appeals.
• Oversee day-to-day UM operations and lead the team, including case review workflows, turnaround times, and staffing models.
• Actively participate in day-to-day utilization management (UM) operations, including direct involvement in clinical reviews and authorization decision-making
• Maintain performance standards for authorization decisions, denials, and appeals management.
• Ensure UM processes meet regulatory, accreditation, and contractual requirements.
• Maintain policies and procedures governing UM processes.
• Manage workflows, staffing models, and case assignments to maintain appropriate review turnaround times in and accurate medical necessity determinations in accordance with clinical guidelines and regulatory requirements.
• Ability to collaborate with analytics to support the development and maintenance of the data governance structure for clinical outcome measures
• Identify trends in overutilization, underutilization, and inappropriate site-of-care decisions.
• Work closely with Compliance to ensure appropriate operational responses to regulatory changes and ensures policy repository is updated based on state specific requirements or regulatory changes
• Adhere to the Policies and Procedures set forth by NeueHealth and performs all additional duties as assigned

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Master’s degree in nursing, business, or other related Healthcare field preferred
• Minimum 10 years’ experience in the population health management arena
• Experience managing a team in a remote work environment
• Experience in program development and management

 LICENSURES AND CERTIFICATIONS

• Active and unrestricted license as a Registered Nurse (RN) in California is required.