AVP Clinical Management / Utilization Management - Behavioral Healthcare in New York, NY at Beacon Health Options

Date Posted: 11/9/2019

Job Snapshot

Job Description

The AVP of Clinical Management is responsible for the direction and leadership of a performance driven care management program including the on-going monitoring of operational performance and workforce management; the development, management and implementation of clinical programs and operations; regional provider strategy performance improvement; client issues; management of medical loss ratio issues; focus on continuous performance improvement; and the monitoring of utilization data and trends in the assigned region.  This position will have oversight of the operational non-clinical and clinical teams ensuring all systems are in place to meet regulatory, client and clinical best practices

What does a typical day look like?

  • Oversee regional CM programs, including utilization, complex case management, intensive case management, care coordination, and case consultation
  • Manage and monitor the Aftercare program including monitoring performance against internal as well as contractual (SLAs, PG) goals and collection of Non Standard Supplemental Data (NSSD)
  • In collaboration with internal and external stakeholders build sustainable integration programs and activities
  • Lead annual production of UM/CM/QM Regional Trilogy Documents, including monitoring work plan activity completion
  • Direct the implementation of the Regional Provider Quality and monitor outcomes
  • Direct and oversee regional clinical and service quality programs led by the Regional Quality lead
  • Develop Regional SOPs to support Corporate wide clinical, quality, and provider strategy policies when needed
  • Train/coach team members on corporate, market, and regulatory developments that impact their roles and functions
  • Ensure that team members are updated on changes in policies and procedures that impact their operations
  • Under the direction of Corporate Quality, ensure compliance with NCQA MBHO and URAC standards and contractual requirements
  • Ensure adequate participation in Corporate Quality Committees, specifically Corporate Quality Committee, Corporate Medical Management Committee, Corporate Utilization Management/Care Management Committee
  • Chair or assign designee for regional clinical, quality and provider Strategy team meetings
  • Oversee and Assign team members to implement new clinical programs, new client implementations assuring all deliverables for clinical, quality and provider partnerships are met
  • Work with the account team, the CMO and the growth officer in the region ensuring client clinical and quality requirements are met.
  • Monitor client clinical and quality CAPs and PGs for the region(OPS)
  • Collaborate with proposals and sales on new business development opportunities for supporting regional growth.
  • Represent Regional Clinical, Quality, and Provider Strategy on cross regional business development opportunities
  • Act as a liaison in URAC and NCQA accreditation and certification activities with Beacon’s Quality Team including: continuous monitoring for standard compliance, document retention and retention of certification and accreditation.
  • Responsible for ensuring that the operations of the regional clinical team are aligned to support the regions MLR and clinical quality targets. Collaborate with Legal on compliance activities for clinical operations to ensure we are maintaining all contractual, legal and accreditation requirements
  • Participate in customer meetings as needed and development and implementation of new business, including contract reviews, proposal requests, sales presentations, and RFP reviews
  • Work with the VP of Clinical Management to identify necessary changes in clinical algorithms to ensure appropriate authorizations are being automated; oversee algorithm adjustments and the operational processes to ensure their accuracy
  • Monitor, analyze, and report on trending of utilization data, working with the Regional Chief Operating Officer (RCOO), Regional Chief Financial Officer (RCFO) and VP Clinical Management to recommend targets; to assess performance against established targets; and to facilitate effective interventions where variance from UM targets may be identified locally or regionally
  • Ensure that performance metrics across all clinical, quality, and provider quality are accurately and consistently monitored
  • Maintain a pro-active quality and process improvement program with in line with corporate policies, procedures and protocols, auditing mechanisms and data reporting systems
  • In collaboration with Corporate Quality and other regional center, proactively identify areas requiring performance improvement, and collaborate with stakeholders to develop improvement activities
  • Continuously monitor utilization management productivity and other operational metrics for region; identify issues related to changes in productivity; direct and oversee appropriate interventions to manage productivity to targets
  • Continuously monitor processes and procedures and develop recommendations to create efficiencies; direct and oversee recommended changes to processes and systems
  • Ensure successful completion of all internal and external accreditation, delegation, compliance, and legal audits
  • Oversee implementation of new clinical business, products, and specialty programs (e.g. Here For You)

 What you Contribute?

Required Experience:

  • 7-10 years of Managed Behavioral Healthcare experience with in a Managed Care company, NY state program or large hospital system
  • Leadership experience in Utilization Management practices and principles
  • Management of Medical loss Ratio, Clinical Services and Quality Management practices and principles
  • NCQA and/or URAC accreditation and knowledge of HEDIS BH measures
  • Senior-level experience with Operations and UM
  • Fluency in Clinical Operations and driving operational efficiencies while managing resulting impacts to MLR
  • Solid understanding of regulatory and accreditation requirements


  • Master’s Degree in a related field i.e. Healthcare Administration, Behavioral Sciences, etc. OR RN with equivalent experience


  • Must have valid, unrestricted NY mental/behavioral license. 

Knowledge, Skills & Abilities:

  • Leadership skills and supervisory experience, including the ability to develop team performance
  • Excellent written and oral communication skills
  • Self-motivated, able to prioritize multiple issues, excellent organizational skills, ability to track multiple projects/tasks and follow through as needed.
  • CQI tools and techniques
  • Ability to manage and coordinate with internal and external departments
  • Ability to manage staff in operations environment
  • Demonstrated leadership skills and experience, including the ability to work cross-functionally, build consensus and develop staff
  • Ability to manage time-sensitive projects and meet deadlines
  • Ability to identify opportunities for improvements and recommend and implement innovative solutions.
  • Able to work collaboratively with internal staff and external providers/clients
  • Must be detail oriented; able to work independently in an ever changing environment
  • Must have excellent communication and negotiation skills.

What Makes Us Different?

  • Here, it’s not just a job – it’s an opportunity to change lives.
  • Our employees are learners, innovators and original
  • Our mission and values guide the way we treat our members, providers and each other.

What We Have to Offer:

  • Healthcare benefits available starting day 1!
  • Health & well-being incentives, such as gym membership reimbursement
  • 401K with company match to help reach your future financial goals
  • Generous PTO, because we know life happens outside of work
  • Tuition reimbursement so you can keep reaching your fullest potential

If Beacon sounds like the place for you, what are you waiting for? Apply with us today to get started!

Beacon Health Options is proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment. EOE/AA/M/F/Veterans/Disabled

At Beacon Health Options, our candidate's data privacy is a top priority. Our recruiting team conducts all communications using official company email (@BeaconHealthOptions.com). Only candidates who have applied for an open position through our Careers page (careers.beaconhealthoptions.com) will be engaged in our interview process. Beacon conducts all interviews in person or over the phone. At no time during the recruiting process will any Beacon recruiter request any financial or personally identifiable information from you.