Clinical Strategy & Performance Director

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Clinical Strategy & Performance Director is responsible for leading clinical program design and performance oversight, working closely with clinical leadership, and product and/or market leads of the respective lines of business. This position is responsible for strategically designing and monitoring clinical programs that support optimal contract, regulatory, accreditation and/or market performance. Reporting to the Sr. Director of Clinical Operations and Performance, the Clinical Strategy & Performance Director develops programmatic framework aligned with enterprise-wide operational solutions, and industry/market standard best practices. 

The Clinical Strategy & Performance Director will work directly with clinical leadership to identify opportunities and clinical programs designed to support optimal contract, regulatory, accreditation and financial performance.  They will independently lead and oversee complex, strategic projects and initiatives, designed to support contractual and performance objectives, working cross-functionally throughout the organization to ensure successful project completion. Project initiatives will be informed by market leadership using performance management KPIs and analytics, contractual requirements, and innovative opportunities identified across the enterprise including analytics, quality and finance.  

The Clinical Strategy & Performance Director supports programs and clinical best practices with the objective of improving health outcomes, preventing hospital readmissions, improving member safety and reducing medical errors, and promoting health and wellness activities, where appropriate. The position may engage in functions of health information technology development that enhances or maintains activities associated with QI initiatives, accreditation, and monitoring, measuring or reporting clinical effectiveness and outcomes.

Our Investment in You:

·       Full-time remote work

·       Competitive salaries

·       Excellent benefits

Key Functions/Responsibilities:

•  Leads strategic model of care and clinical program design with clinical leadership inclusive of program descriptions, staffing models, operational framework design, and technology solution decisions. 
•    Applies innovative approaches and problem solving to optimizing programs in a market, establishing WellSense as a market-leader. 
•    Provides strategic design and ongoing enhancement/innovation for established contracts and in support of future RFPs, service area expansion, or product expansion in existing or new markets. 
•    Responsible for interpreting contract and regulatory changes into timely and within budget program deliverables with measurable goals and outcomes, while maintaining alignment to key quality and accreditation requirements

•    Key point of contact representing WellSense with State regulators and external stakeholders on clinical program design, oversight and performance, as applicable 
•    Identification and development of initiatives and opportunities with external and internal stakeholders for optimizing contract performance in an operationally efficient, resource-sensitive manner. 
•    Uses regulatory reporting and dashboard KPIs to engage with leadership on program oversight, making recommendations on programmatic adjustments to optimize performance. 
•    Able to excel in a highly matrixed organization and drive change management with partners from supporting teams such as Medicaid Operations/Public Partnerships, Product, Care Management, Utilization Management, Quality, Analytics, Finance, Network Management and IT. 
•    Instrumental in identifying and measuring interventions designed to reduce medical expense, and improve financial performance. This work includes ongoing monitoring of metrics and cost savings across products and includes subsequent adjustments in design, intervention and staffing based on data.
•    Monitors trends and reports in order to implement process improvement strategies focused on efficiencies, effectiveness, productivity, and outcomes. Recommends and pursues administrative and process simplification designed to reduce waste, re-work and redundancy.
•    Initiates, supports and coordinates clinical service transformation designed to reduce fragmented care delivered in silos and increase continuity of care for members while reducing health disparities.

Supervision Exercised:

•    None

Supervision Received: 

•    General supervision is received weekly.

Qualifications: 
Education:

•    Bachelor’s degree or equivalent combination of education and relevant experience in a health plan setting required 

Education Preferred/Desirable:

•    Master’s degree in business or health related/public health field preferred
•    Unrestricted RN or SW license preferred but not required 

Experience:

•    5-10 years of healthcare/managed care experience 
•    Progressive experience in healthcare, preferably managed care, including clinical operations, care management/utilization management, program development, health policy
•    Experience in CMS Medicare products, Medicaid, or Commercial, all preferred 

Certification or Conditions of Employment:

 
•    Successful completion of pre-employment background check

Competencies, Skills, and Attributes: 

•    Exceptional written and oral communication skills; able to analyze, compile, format, and present data appropriately to a variety of audiences
•    Proven negotiation skills, relationship building with internal and external stakeholders, and knowledge of risk concepts.
•    Demonstrated ability to think strategically; see ahead to future possibilities and translating them into breakthrough strategies
•    Proven negotiation skills, relationship building and knowledge of risk concepts.
•    The ability to bring people together to leverage their skills, talents, and knowledge to achieve a common purpose. Create synergy – resulting in a combined effort with greater results. 
•    Demonstrated ability to adapt quickly to changing priorities
•    A strong working knowledge of Microsoft Office products 
•    Effective at forming alliances with other departments to develop partnerships and commitment toward completing the project. 

Working Conditions and Physical Effort: 

•    Fast paced office environment
•    Occasional travel may be required.
•    Work is performed in a typical interior/office work environment.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees