KPH Healthcare Services

  • Clinical Operations Manager

    Job Locations US-NY-East Syracuse | US-NY-Gouverneur
    Posted Date 4 weeks ago(12/22/2018 3:43 PM)
    Requisition ID
    # of Openings
    US-NY-East Syracuse
  • Overview

    Scope of Responsibilities: Relies on experience and professional judgment to plan and accomplish assigned tasks and goals that meet the clinical needs of ProAct clients and members, including the development and implementation of cost containment measures.   Responsible for the growth and direction of clinical operations for PBM clients.  Manage the Prior Authorization process to ensure consistency and efficiency in process. 


    Job Summary: Responsible for oversight of all clinical operations including the growth and development of clinical team and clinical offerings. 


    Job Duties:

    • Responsible for the oversight of the Prior Authorization and Appeals process for ProAct members
    • Responsible for the oversight of the internal clinical implementation process for new ProAct clients
    • Partner with Clinical Account Director on the development and implementation of targeted clinical initiatives
    • Responsible for the coordination/implementation of clinical initiatives with internal/external partners
    • Responsible for the development, execution, and reporting on cost saving programs for clients based on the review of utilization data
    • Programs include initiatives to drive mail order utilization, generic conversion and formulary compliance
    • Review, approve, and monitor for compliance of all policies and procedures falling under the scope of clinical practice
    • Responsible for client drug utilization reviews, and analysis
    • Responsible for suggesting appropriate alternative therapies where warranted
    • Responsible for keeping current with changes and trends in the industry
    • Assist with quarterly review meetings with clients
    • Responsible for completing all mandatory and regulatory training programs
    • Perform other duties as assigned


    Educational Requirements:

    • Preferred
    • Pharmacy Degree from an accredited College of Pharmacy
    • Nursing Degree from accredited College of Nursing
    • BS degree in another healthcare-related field


    Experience Preferred:

    • Preferred:  
      • 3-5 Years of experience in a managed care setting
      • 2-3 Years of experience in clinical case management


    Special Conditions of Employment:

    • Criminal background check and/or drug test
    • Initial and continuous exclusion and sanction/disciplinary monitoring


    Required Training:

    • HIPPA Privacy Course and CE Mastery Exam
    • HIPPA Security Course and CE Mastery Exam
    • Fraud, Waste, and Abuse Course and CE Mastery Exam
    • MethGuard Course and CE Mastery Exam





    Job Skills Required:

    • Strong Communication Skills, Must be able to effectively communicate both on the phone and in group setting
    • Clinical Research Skills, must be able to use all available resources to answer question from clients
    • Financial Analysis Skills, must be able to interpret graphs and data for client meetings
    • Strong Microsoft skills in Excel, Word, and Access
    • Strong Public Speaking skills
    • Must be able to work independently


    Management Skills Required:

    • Customer Service: Must provide timely and accurate responses to all business associates and customers
    • Planning: Must develop effective plans, objectives and goals that achieve desired results in a timely manner
    • Organization: Must organize work in a systematic way, establish clear lines of responsibility, and delegate effectively
    • Communication: Must write and speak clearly and effectively at all levels, listen and be attentive to others
    • Decision Making: Gather, analyze data and make and/or implement effective decisions in a timely manner
    • Technology: Must use technology to its fullest potential to achieve department and corporate goals


    Leadership Skills Required:

    • Leadership: Gains acceptance of ideas and accomplishes goals through subordinates, peers and teams
    • Personnel Development: Selects, trains, coaches and develops associates and teams for peak performance
    • Team Work: Must strengthen team performance by sharing information, establishing guidelines and celebrating success
    • Empowerment: Demonstrates positive and active ownership of one’s responsibilities and fosters the same in others
    • Employee Relations: Provides and solicits constructive feedback, evaluates performance and takes corrective action


    Behavioral Traits:

    • Intuitive/Open minded: Must be able to see opportunities, develop and implement creative solutions to complex problems
    • Achievement Drive/Commitment: Driven to achieve goals, objectives and results. Fosters a culture of continuous improvement
    • Positive/Supportive: Inspires and shows faith in others, builds a positive and supportive work environment
    • Flexibility: Ability to adapt to changing business needs. To balance multiple priorities and deliver under pressure


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