Purpose

Provide supervision to clinical staff by overseeing clinical operations in the Utilization Management department. Ensure business strategies, plans, and initiatives are executed/delivered in compliance with governing regulations, internal policies and procedures. The position is responsible for reporting unethical or fraudulent activity related to business operations and adhering to Health New England’s Code of Conduct.

The Clinical Operations Supervisor is responsible for operationalizing initiatives and regulations, using the most efficient and cost effective approaches.

The Clinical Operations Supervisor is the first point of contact for the clinical teams in the Utilization Management department when the UM Clinical Review Nurse is not available.

• Champions a customer focused culture to deepen client relationships and leverage broader Health New England’s relationships, systems and knowledge
• Champions a high performance environment and contributes to an inclusive work environment.
• Understand how Health New England’s culture and the CX Promise should be considered in day-to-day activities and decisions.
• Actively pursues effective and efficient operations of their respective areas in accordance with Health New England’s Values, its Code of Conduct and the Associate Handbook, while ensuring the adequacy, adherence to and effectiveness of day-to-day business controls to meet obligations with respect to operational, compliance, and conduct.

Essen tial Job Functions

• Provide supervision and direction to the clinical staff
• Creates an environment in which the team pursues effective and efficient operations of their respective areas in accordance with Health New England’s Values, its Code of Conduct and the Associate Handbook, while ensuring the adequacy, adherence to and effectiveness of day-to-day business controls to meet obligations with respect to operational, compliance, and conduct.
• · Builds a high performance environment and implements a people strategy that attracts, retains, develops and motivates their team by fostering an inclusive work environment and using a coaching mindset and behaviors; communicating vison/values/business strategy; and, managing succession and development planning for the team.
• · Promote and enhance the level of clinical expertise of staff
• · Assist with interviewing, selecting, and training of new clinical staff
• · Implementing and overseeing clinical operations within the Utilization Management department
• · Oversees the efficiency of clinical operational processes
• · Research methods to improve operations and reduce costs
• Facilitate meetings with the clinical teams to ensure effective departmental communication.
• Monitors the performance, behavior, and attendance of direct reports and provides ongoing feedback to improve performance
• Conduct formal monthly one-on-one meetings with all clinical staff. Provide coaching to associates based on quality results and audits, and develop improvement plans when needed. Provide constructive feedback to clinical staff who need improvement, as well as implements performance improvement plans, when necessary.
• Conducts annual performance reviews for direct reports, and assists them with creating annual performance goals
• Reviews performance trends in order to identify both individual and group training opportunities
• Serves as primary back up to the UM Clinical Review Nurse Team Leads
• Serve as a liaison to ensure communication to clinical staff on upcoming projects, changes, etc.
• Ensure compliance with company policies and regulations
• Ensure operational implementation of updates to clinical processes
• Maintains a strong knowledge of all UM procedures, across all lines of business, in order to serve as a resource to UM staff to help resolve questions and issues and assist with timely processing of prior authorization requests
• · Provide clinical support, as needed
• Performs other duties as assigned

(include secondary Manager if applicable)

• Manager of Utilization Management

• Inpatient Clinical Review Nurses
• Inpatient Clinical Review Nurse Team Lead
• Outpatient Clinical Review Nurses
• Outpatient Clinical Review Nurse Team Lead

• N/A

Internal

• Utilization Management Department

• Health New England Members and Providers

Bachelor’s degree in nursing or higher preferred and a minimum of 5 years of acute and sub-acute care experience, along with a current Registered Nurse license. Moreover, a minimum of four years’ experience performing Utilization Management clinical reviews and knowledge of Medicare and Medicaid regulations is required. Previous leadership experience of 1-2 years preferred.

• Highly developed critical thinking skills
• Excellent assessment, critical thinking, decision making and organizational skills
• Computer literacy and ability to navigate through computer systems
• Excellent written and verbal communication skills, including delivering presentations
• Excellent time management skills with the ability to manage multiple priorities
• Ability to manage an assigned caseload independently
• Strong teamwork skills, ability to work collaboratively in consultation with team members