The Senior Director of Clinical Quality will oversee and set the strategic direction for OptumRx's Clinical Quality Management program, encompassing numerous areas which include, but are not limited to: Formulary/UM, Clinical Data / Analytics / Reporting, Drug Intelligence Services, Clinical Consulting, MTM, Prior Authorization and other Clinical Products and Services. Primary Responsibilities: Determine strategic direction for Clinical Quality Mgmt (quality of care, compliance and Quality Improvement), PBM, Mail and Specialty Accreditation and Health Plan Delegation Services (e.g., URAC, NCQA, etc...), Clinical Policy & Procedures, and Clinical Performance Metric Development, Refinement and Monitoring. Continual development, implementation and evaluation of new and current Clinical Quality Oversight Programs and associated reporting metrics and outcomesMaintain close working relationships / dialogue with key customers (internal and external) to help ensure optimal quality and compliance in clinical products and services.Assist clinical teams in the development of key QI and QA processes and metrics; training and monitoringLead / chair activities of a Clinical Quality Oversight Committee; Monthly MTM Review; Monthly Clinical PA / Appeals Review Serve as an active participant in various other cross-departmental committees / meetings where clinical quality representation is essential (e.g., Specialty QM; Med D Guidance; Operational Policy Mgmt; Clinical Utilization Mgmt; Med D Audit, etc...)Oversee quality monitoring of external clinical vendor activity (e.g., contracted IROs) to ensure optimal quality and compliance with their subcontracted functionsWork closely with OptumRx Government Relations team to ensure that clinical programs comply with federal and state regulations, partnering with program owners to develop policy, programs, and processes as neededOversee, on an as needed basis, the collaborative research and formal addressing of clinical Quality of Care issues including development and communication of corrective action plans as needed Manages and provides oversight to clinical staff (5)Reports regularly to senior leadership on quality improvement initiatives and recommendations
Required Qualifications: Bachelor's degree required, Advanced degree or Pharmacy degree highly preferred10+ years of clinical and/or managed care pharmacy experience10+ years of leadership experience including managing leadership levels5+ years hands-on experience driving quality improvement initiatives and implementations 5+ years involvement in clinical pharmacy strategy inclusive of some of following:Prior Authorization operational functions, clinical development/review/ oversightUtilization management criteria development/reviewPharmacy & Therapeutics/Drug InformationAnalytics and reportingStrategic Program developmentCurrent industry issues and trendsAccount ManagementDemonstrated ability to work collaboratively cross-functionally to deliver resultsProficient in Microsoft Word, Excel, PowerPoint, OutlookStrong written and verbal communication and presentation skills Preferred Qualifications: PharmD Current and unrestricted Pharmacist or RN license in the state of California or IllinoisMBA or other advanced related degreePBM and/or Health Plan ExperienceHands on experience with P&T and Formulary Management Experience successfully leading project teams Experience working with agencies such as NCQA, URAC, CMS or similarExperience preparing and delivering formal presentationsUnderstanding of and experience working with Lean/Six Sigma principles and toolsCareers with OptumRx. We're one of the largest and most innovative pharmacy benefits managers in the US, serving more than 12 million people nationwide. Here you'll fill far more than prescriptions. As a member of one of our pharmacy teams, you're empowered to be your best and do whatever it takes to help each customer. You'll find unrivaled support and training as well as a wealth of growth and development opportunities driven by your performance and limited only by your imagination. Join us. There's no better place to help people live healthier lives while doing your life's best work.(sm) For more information on our Internal Job Posting Policy, click here. Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.