It’s Time For A Change…Your Future Evolves Here
Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans.
Are we growing? Absolutely—70.3% in year-over-year revenue growth in 2017. Are we recognized? Definitely. We have been named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016 and 2017, and one of the “50 Great Places to Work” in 2017 by Washingtonian, and our CEO was number one on Glassdoor’s 2015 Highest-Rated CEOs for Small and Medium Companies. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.
Encouraged by the success of provider-led health plans in other states in improving health care quality and lowering costs, Evolent Health is working together with Lee Health to support Vivida Health Plan. Vivida intends to meet the Agency for Health Care Administration objectives to drive similar outcomes for Florida Medicaid members locally in Region 8, which includes Sarasota, De Soto, Charlotte, Glades, Lee, Hendry, and Collier counties. Evolent’s clinical, financial, and operational resources will enable the innovation and infrastructure needed for the immediate launch and scale of Vivida. Evolent Health is proud to support AHCA and Vivida’s mission: Vivida Health connects you with the care and community services you need. We are local doctors helping you and your family stay healthy so you can focus on what’s truly important: each other.
Evolent Health is looking for a Manager, Clinical Operations to be a key member of our team. Reporting directly to the Managing Director of Clinical Operations, this individual will play a critical role in executing Evolent Health’s mission by monitoring clinical performance and ensuring adherence with the Plan’s protocols, requirements and standards. Must have a Florida or Compact State Nursing License.
The Manager, Case Management will serve as the liaison to the clinical operations and leadership with matrix responsibilities to the Plan's Compliance Director, Manager of Delegation Oversight, the Director of Quality Improvement and Director of Health Plan Operations. This position will successfully service, monitor and grow relationships with both internal and external business partners to implement ongoing clinical operations monitoring, resolve barriers, influence decision making and enable achievement of improved clinical quality outcomes and processes
What You’ll Be Doing:
- Serve as a liaison between external business partners, internal team members and partner organization providing clinical leadership of SNP clinical requirements including utilization management (UM), care management (CM), quality improvement (QI), appeals and other requirements outlined in the Model of Care (MOC
- Provide guidance and support on clinical operations
- Partner with internal and external business partners to drive towards resolution of clinical operations-related issues with an emphasis on root cause analysis and resolution of problems
- Develop deep understanding of clinical system/platform capabilities, processes and procedures; identify and document limitations of business partners systems, tools and resources and provide recommendations to meet plan requirements
- Confirm that all benefit components, clinical protocols and administrative rules have been set up within the clinical payment system; monitor to ensure system and processes are aligned with the requirements as specified in the plan materials (i.e. MOC, evidence of coverage, summary of benefits, PBB)
- Regularly monitor and analyze clinical operations performance reports and data to inform decision-making, process design or improvement and program modification or implementation; take timely corrective action and follow-up to ensure positive outcomes
- Compile, review and analyze necessary clinical operations dashboards for management review; create and report operational tracking metrics and dashboards for monitoring clinical operations and performance
- Identify and advise UM, CM, QI, Medicare Operations and other operational leadership of trends, problems, and issues as well as recommended course of action; ensure timely communication; participate in the development and implementation of solutions
- Monitor adherence to the efficiency and service level goals including volume, processing, timeliness, accuracy and other metrics, internally and externally
- Compose, submit and track clinical system questions and configuration requests to correct identified systemic clinical operations issues
- Prioritize issues identified by business partners, internal team members and/or partner representatives and monitors progress in the resolution of the issues
- Coordinate the configuration, set up and/or modification of the clinical system/platform following business partner protocols
- Confirm that desk level procedures, processes, and policies for clinical operations have been finalized and are aligned with the plan requirements
- Coordinate corrective action plans with partner/client and business partner operations/administrator to resolve issues
- Support internal plan team members with the resolution of daily issues
- Support the clinical and quality leadership team efforts by developing solutions to improve effectiveness and identify continuous improvement opportunities and initiatives
- Work with other departments to identify and resolve problems leading to incorrect MOC requirements, UM, CM, QI and/or appeals-related processes
- Provides management assistance for activities specific to the DSNP case/care management program.
- Assist management in the identification and coordination of the necessary clinical operations and service training needs; monitor and implement educational and process interventions based on data, trends and identified opportunities.
- Serve on various committees and attends required meetings
- Perform other duties and projects as assigned
The Experience You Need (Required):
- Bachelor’s Degree or equivalent
- Must have a Florida or Compact State Nursing License.
- 3-5 years of experience within a health plan, managed care organization, third-party administrator, or other healthcare entity.
- At least 2 years experience in a clinical, quality or closely-related setting
- Prior supervisory or team lead experience
- A proven track record of success with both individual and collaborative problem-solving, showing demonstrable evidence of sound judgment and decision-making.
- Ability to work collaboratively across partner/organizations
- Experience with Medicare Advantage plans
- Exceptional organizational skills
- Exceptional communication skills
- Models leadership and takes initiative
Finishing Touches (Preferred):
- Master’s Degree in healthcare, healthcare related discipline or business-related discipline
- 5 - 7 years of experience within a health plan, managed care organization, third-party administrator, or other healthcare entity.
- 3 - 5 years experience in a clinical, quality or closely-related setting
- Prior management experience
- Experience in clinical information system report design/development
- Project management experience or equivalent experience leading cross-functional teams to successful completion of projects Entrepreneurial mindset geared toward the creation, execution and continuous improvement of clinical health plan operations and implementations
- Excellent written and oral presentation skills
- Demonstrated exceptional active listening and communications skills
Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.