Director, Clinical Guidelines

  • 16945 Northchase Dr, Houston, TX 77060, USA
  • Full-time

Company Description

HealthHelp - A WNS Company (www.HealthHelp.com), is the leader in the field of healthcare utilization & care management. We have gained this position by actively working to change out-of-date practices with a collaborative, non-denial based approach. Our methodology helps payors achieve a higher return on investment, gives providers education programs that better inform physicians, and ensures quality and safety for the patients needing treatment.

HealthHelp’s innovative approach and strong IT capability in specialty benefits management means that staff will move healthcare forward when provided with evidence-based solutions and second opinions. HealthHelp's staff is comprised of healthcare professionals who make a difference every day. HealthHelp has a desire to fill their company with talented and innovative people who want a career path filled with success and personal growth.

Our specialty benefits management services are broad and include, Cardiology, Oncology, Radiology, Radiation Therapy, Sleep Care, and Musculoskeletal Care. HealthHelp has two locations in Houston, one a corporate office and the second a state-of-the art contact center. HealthHelp is also proud to have another such contact center in Albany, New York.

WNS Global Services Inc. (NYSE: WNS) is a global Business Process Management (BPM) leader. WNS offers business value to 400+global clients by combining operational excellence with deep domain expertise in key industry verticals, including Banking and Financial Services, Consulting and Professional Services, Healthcare, Insurance, Manufacturing, Retail and Consumer Packaged Goods, Shipping and Logistics, Telecommunications, Travel and Utilities. Globally, the group’s over 44,000+ Professionals serve across 60 delivery centers in 16 countries worldwide.

Job Description

Position Summary:

The Director of Clinical Guidelines will be responsible for providing leadership and guidance to a team of professionals on all issues related to clinical guidelines, clinical rules, health plan medical policies, outcomes research, and coding. The position will also support HealthHelp leadership in strategic and tactical issues related to developing a high-functioning team focused on clinical excellence.

•     Responsible for research and compilation of evidence-based medicine findings related to both new and existing clinical criteria for all modalities reviewed

•       Evaluates clinical criteria Indications/rule sets for duplication, clinical appropriateness, potential consolidation, and alignment with associated Local Coverage Determinations / National Coverage Determinations

•     Coordinates the submission of new and updated clinical criteria and corresponding clinical guidelines for review/approval by Specialty Physician Advisory Committee (PAC) and Chief Medical Officer in conjunction with implementation initiatives and scheduled annual review of existing criteria

•     Responsible for quality audit of software enhancements pertaining to clinical criteria prior to their implementation to ensure potential issues affecting Clinical Review are identified and resolved

•     Collaborates with Program Management and Specialty Program Medical Director when clinical rule sets are not performing as expected to determine cause; provides support to ensure resolution is achieved

•     Responsible for accurate and complete documentation of clinical guidelines based on clinical rule sets and for ensuring up-to-date clinical guidelines are maintained on the HealthHelp website

•     Serves as health plan liaison for medical policies: conducts comparative analyses of health plan medical policies against HealthHelp criteria and related Local Coverage Determinations/National Care Determinations; proactively presents any differences identified to Specialty Program Medical Director and coordinates with Client Services to submit Medical Director recommendations to health plan

•     Responsible for surveillance of industry professional organizations, key health plans, and competition for trends and enhancements affecting clinical guidelines at least on an annual basis

•     Responsible for coordination of current outcomes research projects with research scientist

•     Responsible for arranging necessary clinical and administrative resources in HealthHelp for supporting outcomes research

•     Responsible for planning and promoting outcomes research ideas to Client Services for potential value creation with all clients

•     Provides periodic updates on clinical guidelines and outcomes research for internal and external distribution

•     Serves as internal liaison and subject matter expert for all clinical criteria, clinical guidelines, outcomes research, and coding

•     Recognizes and informs management of critical issues

•    Adheres to all regulatory requirements and complies with HealthHelp policies and procedures

•     Upholds professional standards and performs all work in a manner respectful of others

•     Provides a high level of service and support to both internal and external clients

•     Promotes business focus which demonstrates an understanding of the company's vision, mission, and strategy

•     Performs other duties as assigned to meet business needs

Qualifications

Skill Requirements

•     Excellent listening, oral, and written communication/presentation skills

•     Ability to communicate complex information in a clear and concise manner

•     Strong problem solving, interpersonal, and customer service skills in both face-to-face and remote settings

•     Ability to work on multiple projects simultaneously and prioritize work to meet adapting deadlines

•     Ability to recognize potential and actual problems and work effectively within a team to develop appropriate solutions and implement effective action plans to address the problems

•     Demonstrated knowledge and experience in using critical thinking skills

•     Proficient with Microsoft Office Suite and Windows

•     Proficient with setting up webinars and multi-participate conference calls

 

Qualifications

•     Graduate of an accredited school of nursing

•     Current active unrestricted RN license in a state or territory of the U.S. required

•     Two years of prior experience in direct clinical care or managed care setting required

•     Five years of previous management experience required

•     Previous experience developing and reviewing clinical program guidelines highly desired

Additional Information

All your information will be kept confidential according to EEO guidelines.