As one of the largest pharmacy benefits managers in the United States, UnitedHealth Group provides a professional culture where you're empowered and encouraged to exceed the expectations of our members, with better schedules than retail and more reach than any hospital. Join us and start doing your life's best work.(sm) The Senior Director of Clinical Quality will oversee and set the strategic direction for implementation of and reporting out on OptumRx Clinical Quality Management program, encompassing numerous areas which include, but are not limited to: Prior Authorization, MTM, Clinical Data / Analytics / Reporting, Drug Intelligence Services, Formulary / UM and other Clinical Products and Services. Primary Responsibilities: Determine strategic direction for Clinical Quality Management (quality of care, compliance and Quality Improvement), PBM 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 outcomes Maintain 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 monitoring Lead / 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 Management; Clinical Utilization Management; 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 functions Work 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 needed Oversee, 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 Manage and provide oversight to clinical quality management team Reports regularly to senior leadership on quality improvement initiatives and recommendations
Required Qualifications:Bachelor's degree required, Advanced degree or Pharmacy degree highly preferred 8+ years of clinical and / or managed care pharmacy experience 8+ years of leadership experience including managing leadership levels 5+ years hands-on experience driving quality improvement initiatives and implementations Strong demonstrated incorporation of metrics into all aspects of daily work 5+ years involvement in clinical pharmacy strategy inclusive of some of following: Prior Authorization operational functions, clinical development / review /oversight Utilization management criteria development / review Pharmacy & Therapeutics / Drug Information Analytics and reporting Strategic Program development Current industry issues and trends Account ManagementDemonstrated ability to work collaboratively cross-functionally to deliver results Proficient in Microsoft Word, Excel, PowerPoint, Outlook Strong written and verbal communication and presentation skillsPreferred Qualifications:Advanced degree or Pharmacy degree PharmD Current, unrestricted Pharmacist or RN license in the state of California or Illinois MBA or other advanced related degree PBM and / or Health Plan Experience Experience successfully leading project teams Experience working with agencies such as NCQA, URAC, CMS or similar Understanding of and experience working with Lean / Six Sigma principles and tools Hands on experience with P&T and Formulary Management Experience preparing and delivering formal presentationsUnitedHealth Group is working to create the health care system of tomorrow. Already Fortune 6, we are totally focused on innovation and change. We work a little harder. We aim a little higher. We expect more from ourselves and each other. And at the end of the day, we're doing a lot of good.Through our family of businesses and a lot of inspired individuals, we're building a high-performance health care system that works better for more people in more ways than ever. Now we're looking to reinforce our team with people who are decisive, brilliant - and built for speed.Come to UnitedHealth Group, and share your ideas and your passion for doing more. We have roles that will fit your skills and knowledge. We have diverse opportunities that will fit your dreams.Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and 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. Job Keywords: Senior Director of Clinical Quality, Irvine, California, CA, Schaumburg, IL, Illinois
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.