Gerente de Programas Clinicos Especiales

Regular

Exempt

GENERAL DESCRIPTION:

Develops, implements, manages, and monitors the work plan(s) designed for Special Clinical Programs to ensure compliance with the established goals. Responsible for evaluating the operational processes of the assigned programs to ensure that they adequately comply with the needs, objectives, and procedures established by MCS and the applicable regulations. Designs, develops, and communicates policies, operational guidelines, and/or clinical protocols. Works on the barriers that impact the compliance and quality of services for insureds in the clinical programs and/or assigned initiatives. Analyzes and interprets operational and utilization reports.

ESSENTIAL FUNCTIONS:

• Designs, develops, implements, and manages the work plan to execute the activities of special clinical programs and/or delegates of both MCS business lines, considering the deadlines to ensure their compliance.
• Develops and participates in the process of designing cost containment strategies inherent to the assigned clinical programs and Medical Efficiency Management Projects (EMM).
• Develops and participates in surveillance, monitoring, and analyzing measurement mechanisms (dashboards, production, utilization, operational, and cost-efficiency metrics) to evaluate and document the achievement of clinical results by the assigned special clinical programs.
• Acquires the tools identified as necessary for the optimal functioning of the Special Clinical Programs.
• Analyzes and interprets reports generated by the Business Intelligence Unit, among others, in collaboration with management to evaluate the effectiveness of the assigned programs.
• Creates, reviews, and keeps updated the Policies and Procedures, clinical protocols, and process flowcharts and develops activities for compliance and dissemination.
• Identifies, documents, and raises existing or potential situations that may negatively impact the results of a delegated clinical program and proactively develops strategies to overcome them.
• Manages periodic meetings and prepares presentations for the contracted provider(s) and business partners to discuss operational reports and the results of the clinical management of the insureds participating in projects, initiatives, and/or assigned programs of both business lines.
• Discusses the results of quality reviews and areas of opportunity with medical groups.
• Participates as a clinical resource in interdisciplinary interventions performed on insureds participating in clinical programs, including, but not limited to insureds with chronic, fragile, and/or end-of-life conditions through case discussions with the interdisciplinary team in charge of the care of the insured as required.
• Participates in and facilitates the development and implementation of improvement plans based on monitoring and analyzing the effectiveness results of the assigned programs and initiatives.
• Participates in analyzing invoices for the services provided by the contracted provider.
• Participates in the annual review of contractual agreements with contracted providers, submits recommendations to improve processes, results, and costs, and addresses identified areas of opportunity, as required.
• Periodically evaluates the operational processes, staffing patterns, and resource needs, including technological equipment and any other matter that may be affected by the growth in insureds, entry or exit of products and/or clients, and development of new goals in the organization.

• Participates, as required, in the process of planning budget requirements for personnel, performance, supplies, and equipment. Appropriately justifies and distributes the budget allocated for the use of resources.
• Supervises, monitors, trains, evaluates, and corrects, among other tasks required to fully fulfill their role as supervisor of the personnel assigned to their unit, ensuring that the performance of their personnel complies with the assigned work plan and the tasks inherent in their positions and that their conduct complies with the Company's policies, standards, rules, and procedures.
• Complies fully and consistently with the Company's standards, policies, and procedures and the local and federal laws applicable to our industry, business, and employment practices

MINIMUM QUALIFICATIONS:

Education: Bachelor's degree (Master's degree, preferable) in Nursing Sciences, Health Information Management and/or Health
Services Administration, preferably.

Experience: At least five (5) years of experience in a similar position working with clinical programs, care environments, health services, clinical cases management, medical services utilization, discharge planning, and personnel supervision.

Certifications/Licenses: For Bachelor's in Nursing: Valid license and membership for Nursing Practice in PR and/or license for Health Services. Administration. For Master's degree in Health Information Management: Certification, RHIA, preferably. Case Manager for all grades, preferably.

"Proven experience may be replaced by previously established requirements."

Others: Knowledge of guidelines, ICD-10, and CPT. Professional

Languages:
Spanish – Advanced (writing, conversational, and comprehension)
English – Intermediate (writing, conversational, and comprehension)

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