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The C&S Plan Chief Medical Officer has accountability for ensuring that local health plan, United Clinical Services and UHC initiatives focusing on clinical excellence, quality ratings improvement, appropriate inpatient and outpatient utilization, health care affordability, health system transformation including provider network issues, mandated provisions and compliance, growth and focused improvement are implemented and successfully managed to achieve goals.
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Internal Operations and Technology: Support efforts to improve the efficiency of health plan operations (utilization management, claims payment, provider contracting) to reduce friction for members, providers, and associates.
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Document all activities in the Health Plan's care management tracking system following HealthSuccessfully engage member to develop an individualized plan of care in collaboration with their primary care provider that promotes healthy lifestyles, closes gaps in care, and reduces unnecessary ER utilization and hospital readmissions.
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Role and Responsibilities:The ESP Senior Medical Director provides leadership and management for the clinical staff of the Elder Service Plan - Program for All Inclusive Care for the Elderly (PACE) Centers as well as provides primary care, including routine health maintenance, management of chronic conditions, and management of acute illnesses.
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For nearly two decades, Wexford Health has consistently delivered proven staffing expertise and a full range of medical, behavioral health, pharmacy, utilization management, provider contracting, claims processing, and quality management services.
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Completes ongoing audits of BHU team documentation to ensure CMS compliance with all Pre-admission, Post- admission Physician Evaluation, evaluations, Plan of Care, team conference notes and daily provider, therapy, and nursing documentation.
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Access : Ensure Humana members with behavioral health needs have access to appropriate and high-quality behavioral health care by optimizing network design, benefit design, care management, and referral pathways.
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Oversee regional utilization management and case management for inpatient cases (acute care hospital, LTAC, Acute rehab, SNF) according to the Humana's Medicaid policies and procedures.
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Deep understanding and experience with behavioral health strategy and operations in a managed care setting. You will also facilitate the delivery of high quality, appropriate, and cost-effective behavioral healthcare for Humana's members, which includes guiding the development and implementation of behavioral health strategies, tactics, policies, and programs to ensure appropriate outcomes and drive reductions in total cost of care.
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He/she will understand the behavioral health ecosystem-including gaps and opportunities to improve the value and quality of care-especially for seniors. Innovation : Support behavioral health innovation including increasing access to virtual and specialty care and advancing value-based payment models.
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Work collaboratively with enterprise teams to evaluate and synthesize data to inform clinically appropriate, cost-effective solutions to advance the behavioral health management of members.
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In this role, you will be a key enterprise leader, with responsibility for evolving Humana's behavioral health strategy, with a focus on our 5 million Medicare members. Analytics and Measurement : Evolve enterprise approach to behavioral health outcome measurement to improve our ability to identify trends, highlight areas for improvement, establish tactics for advancing outcomes, and evaluate the impact of our strategic initiatives.
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Establish and maintain external relationships to ensure awareness of leading-edge innovation and policy changes in behavioral health; represent Humana and Humana's behavioral health strategy in external venues.
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External Partnerships : Explore, evaluate, and implement novel partnerships-with national and community-based organizations-that will expand Humana's ability to impact behavioral health outcomes.
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Deep understanding and experience with behavioral health strategy and operations in a managed care setting, combined with an MD or DO degree and Board certification in an approved ABMS Behavioral Health Medical Specialty with 5 years of established clinical experience.
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care provider behavioral health utilization management plan jobs in Sherwood, Oregon
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