Director, Clinical Operations

Job Description

Job Description

Description :

Mass Advantage is a Medicare Advantage health plan, located in the heart of Worcester County, headquartered in Worcester MA. Mass Advantage is owned and designed by UMass Memorial Health providers with their patients’ needs in mind.

We are looking for a Director of Clinical Operations responsible for the oversight of clinical functions, including utilization management, care coordination, and integrated care processes, to ensure the delivery of high-quality, cost-effective care. Reporting to the Chief Medical Officer, this role will work collaboratively with the Chief Executive Officer, VP of Operations, Chief Compliance Officer, Chief Financial Officer, other senior leadership, and other health plan employees to develop and implement clinical strategies that align with organizational goals. The Director will play a key role in establishing policies and procedures, ensuring compliance with CMS and accreditation standards, and driving performance improvement initiatives. Experience in start-up environment with desire to build the organization’s sustainable and scalable clinical operations is key to success.

Utilization Management and Clinical Oversight

• Perform reviews of operations and decision of delegated entity on services and determine the medical appropriateness of inpatient and outpatient care, following evaluation of medical guidelines and benefit determination.
• Utilize clinical skills to telephonically provide and facilitate conversations around utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines in conjunction with the delegated entity, as applicable.
• Ensure evidence-based referral management, inpatient concurrent review, and care management to promote efficiency, effectiveness, and compliance with regulatory standards.
• Provide industry-standard utilization and cost data measured against program-wide regional and external benchmarks / goals for all areas of service managed by the department.
• Complete UM delegation responsibilities.

Care Coordination and Integrated Care

Policy Development and Compliance

Performance Improvement and Reporting

Collaboration and Leadership

Requirements :