Director of Clinical Review, Post-Acute Care Utilization Management and Review
Elevance Health

Description

A proud member of the Elevance Health family of companies, myNEXUS is the leader in health resource optimization, focused on transforming how healthcare is delivered and promoting the advancement of care for the people we serve.

The MyNEXUS Clinical Operations team is looking to hire a Director of Clinical Review Team for the utilization management of post-acute care services [skilled nursing facilities (SNFs), Inpatient Rehab facilities (IRF), and Long-term acute care facilities (LTACH)] for its covered patients nationally. This People Leader will be responsible for leading multiple teams of clinicians (therapists, nurses, LPNs) charged with promoting quality member outcomes, optimizing member benefits, and promoting effective use of resources.

Responsible for the same duties as the Director I Medical Management In addition to managing an environment of larger, more significant scope, complexity and change in multiple operations centers.

Primary duties may include, but are not limited to: Oversees care management operations across a wide range of products, clients and states including meetings with key major account clients. Leads and participates in cross functional corporate teams which design and implement new care management programs that may impact multiple lines of business. Develops and implements process and program redesigns. Leads multiple teams of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources. May direct multiple medical management programs including utilization management, case management, demand management and disease management programs, which typically support multiple lines of business. May also manage appeals for services denied. Staff size is typically large, located in multiple sites and/or states and utilizes multiple systems. Ensures adherence to all contract, regulatory and accreditation requirements. Develops short/long-term objectives and monitors processes and procedures to ensure consistency with the enterprise and compliance with state and federal regulations. Collaborates with matrix Care Management partners (such as IM or PE&C) to resolve issues or find solutions. Manages budget and special projects. Hires, trains, coaches, counsels, and evaluates performance of direct reports.

Requires BS in nursing or related health care field and minimum of 8 years of experience in a health care environment (i.e. acute care) which includes prior management experience; or any combination of education and experience, which would provide an equivalent background. Current active unrestricted RN license or Therapist license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States preferred.

Highly preferred skills and experiences:

-5-8+ years acute care clinical experience in SNFs, IRFs, and/or LTACs

-Experience in Utilization Management/Utilization review for managed care services.

-Experience with a Medicare health plan (commercial and Medicaid plans also preferred)

-Subject matter expertise in skilled nursing, rehabilitation, and long-term acute care facilities

-3+ years of people management experience required.

-Strong experience in new program build, implementation, and execution

-Excellent people leadership skills

For candidates working in person or remotely in the below locations, the salary* range for this specific position is $127,360 to $229,480

Locations: California; Colorado; Nevada; Washington State; Jersey City, NJ; New York City, NY; Ithaca, NY and Westchester County, NY

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Be part of an Extraordinary Team

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.

We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide - and Elevance Health approves - a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World's Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealth.com. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ability@icareerhelp.com for assistance.