Senior Director, Health and Wellness Clinical Services

Care Management Irvine, California Irvine, California


Description

Western Growers Assurance Trust (WGAT) was founded in 1957 to provide a solution to a need in the agricultural community — a need for employer-sponsored health benefit plans not previously available from commercial health insurance carriers. WGAT is now the largest provider of health benefits for the agriculture industry. Pinnacle Claims Management (PCMI) is a 3rd party administrator that provides health benefits administration and related services to companies that self-fund their insurance.

WGAT and PCMI's mission is to deliver value to their employer groups by offering robust employer solutions that meet the needs of a diverse workforce. By working with us, you will join a dedicated team of employees who truly care about offering quality employer solutions and excellent customer service to participants. If you want to start making a difference working in the health care industry, then apply today!

To learn more watch our Company Video!

Job Description Summary

Reports to the Vice President of Health Management and Clinical Services with four direct reports: Nurse Supervisor, Manager of Health and Wellness, Manager of Clinical Services, and Behavioral Health Specialist.

This is a high-level position responsible for directing and overseeing Western Growers Assurance Trust’s (WGAT) and Pinnacle Claims Management Inc.’s (PCMI) third party and direct care management/utilization, disease management, and wellness programs, clinical services and clinic management divisions, objectives and  initiatives. This position is responsible to provide leadership, direction, oversight, and operational management for the organization’s health management functions.

 

This position builds and maintains strong collaborative partnerships with key partners in the health management areas including Utilization Management, Medical Management, and  Policy including Quality Medical Review and Appeals, Pharmacy, and Provider Integration to identify, develop, implement, and monitor performance metrics related to care management, clinical operations, and clinical services. This position will interface externally with our clients providing a premier level of customer service. This position is involved with the sales strategy process for new sales and retention for the health management division.

Qualifications

  • BA/BSc in clinical administration, medical science, healthcare management, or related field; MSc/MA is preferred; a minimum of eight years’ experience with progressive responsibility in clinic supervision, program management, health plan medical management.
  • A thorough understanding of the healthcare market, managed care, physician organizations, and knowledge of relevant state and federal regulations.
  • Thorough and solid knowledge of clinical care, health care, and managed care delivery systems. This includes standards of medical practice, health plan benefits structure, and the utilization and case management.
  • Requires a high level of computer literacy, with the ability to use MS Office in the areas of Word, Excel, PowerPoint, and Outlook at an intermediate level or higher.
  • Working knowledge of medical coding systems and methodologies.
  • Ability to lead and direct staff in the area of clinic services, health and wellness, and managed care.
  • Must possess excellent verbal and written communication skills, as well as strong analytical
  • Must have the ability to travel to prospective and existing clients, members, and providers on an occasional
  • Verifiable, clean DMV record and the ability to travel to various locations throughout the U.S. up to 20% of the

 Duties and Responsibilities

Management & Leadership

  • Perform management responsibilities to include, but not limited to: involved in hiring and termination decisions, coaching, and development, rewards and recognition, performance management, and staff
  • Develop and prepare annual budgets and review monthly expenses. Provide advice and assistance with cost analysis, fiscal allocation, and budget preparation.
  • Plan, organize, direct and control the day-to-day operations of the department’s staff.
  • Develop and implement policies and programs as
  • Support strategic planning efforts for all clinical and health management
  • Supports strategic customer solutions by assisting sales, account management, and marketing, as needed, in upselling products and services, driving new business growth, maximizing retention, and driving support channel strategies to build brand presence in the healthcare marketplace
  • Lead efforts in the monitoring, and reporting, of key metrics to manage all clinical and health management programs.
  • Develop, manage, and lead a team of 3A+ self-accountable
  • Develop a culture of real, personal accountability by modeling the behavior that defines
  • Instill a culture of safety and expectation, within your respective area/s.
  • Require direct reports to hold themselves accountable to high standards of, performance and personal conduct, in a clear, helpful, straightforward
  • Conduct one-on-one conversations with every direct report, quarterly focused on their 3A+ e.g. capabilities, impact, and
  • Make decisions and choices, impacting staff, by using the: selection and hiring, clarifying roles and objectives, managing performance, correction & discipline, and termination steps as outlined in the “Outward Mindset Skills for Leaders”

Care Management and Wellness

  • Provide expertise to product development in the creation of applications and
  • Direct the implementation of each new Health Management program with the necessary communication between the operational areas, sales team, and any external vendors as
  • Review data and other key metrics for internal and external reporting for all areas within the
  • Maintain regulatory compliance in all areas, develop compliance strategies for new areas.

Clinical Services

  • Oversee day-to-day clinic operations to ensure smooth patient experience and high-quality medical care.
  • Monitor utilization and revenue for all clinical service lines and report to leadership on their success.
  • Ensure adherence to all state and federal laws.
  • Review and maintain department standards to ensure compliance with WGAT and PCMI operational quality standards.

Other

  • Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.
  • Maintain a clean DMV record and the ability to travel to locations throughout the U.S. (mainly California and Arizona) up to 20% of the time.
  • All other duties as assigned.

Physical Demands/ Work Environment

The physical demands and work environment described here are representative of those that must be met by an employee to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to travel to both indoor and outdoor areas that can vary in exposure and temperature. The employee is frequently required to operate a motor vehicle, use objects, tools, or controls, and/or required to lift up to 50lbs. The noise level in the work environment is usually moderate.