Reporting to the VP of Clinical Strategy & Implementation, this position will lead the successful implementation and ongoing management of Health Edge's Guiding Care solution suite for Neighborhood. The Clinical Information Management Director will bring best practices in utilization management (UM) case management (CM) and grievances and appeals (GAU) to the implementation to support best-in-class functionality and workflows.

The Director will work closely with IT and Operations teams to ensure the system is implemented on-time and within budget. The Director will engage cross-functional stakeholders to develop policies and procedures, training curriculum and change management plans to support team engagement and successful system adoption. The Director is a collaborative team player who is data-driven and motivated to impact the health of members. They are execution-oriented and excel at building relationships and using indirect influence to drive action.

This position requires a deep understanding of the Guiding Care software and specific experience implementing this solution at a health plan.

Duties and Responsibilities:

Responsibilities include, but are not limited to:

• Lead the implementation of the Guiding Care clinical management system within the clinical division to support best in class care management, utilization management, and grievance & appeals operations.
• Provide subject matter expertise to inform best practice CM, UM and grievance and appeals workflows. Establishes relationships with key operational leaders to better understand the business need.
• Serve as the primary interface and provide expertise between clinical and operations areas, developing, translating and operationalizing clinical business requirements.
• Develop and execute clinical test scenarios
• Make critical business decisions leveraging business unit and leadership consultation. Provide clinical division leadership with critical information to inform decision making
• Develop and design policies, procedures and desktop procedures to support system implementation

• Lead training and change management efforts pre and post implementation to ensure effective use of the system and fidelity to workflows
• Implement quality assurance systems to promote fidelity to workflows
• Ongoing monitoring of technology solution utilization with ability to analyze requirements, gaps, issues, risks, and workflow enhancements.
• Assess system functionality against requirements post go-live
• Manage relationships between Operations, IT and Clinical areas post go-live.
• Oversees and provides on-demand, friendly, and thorough customer service to application users and trainees
• Develop system governance structure
• Identify and work with cross functional areas to implement system enhancements
• Provide regular status updates to senior leadership
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.

Qualifications

Required:

• Bachelor's degree in Health Informatics or health care related field or equivalent education and relevant work experience in lieu of a degree
• Minimum of five (5) years' experience managing clinical information management systems
• Minimum three (3) years' experience implementing Health Edge's Guiding Care system, including the care management, utilization management, and appeals & grievances modules
• Minimum of three (3) years' experience in a program management role with demonstrated ability to manage complex projects (setting clear goals, managing stakeholders, developing budgets, identifying roadblocks, designing solutions, and tracking progress against deadlines)
• Demonstrated knowledge of utilization management, care management and grievance and appeals regulatory and accreditation requirements
• Demonstrated knowledge of clinical best practice workflows at a health plan
• Strong execution-oriented mindset with proven ability to lead people across multiple business areas and drive successful execution of complex initiatives
• Proven ability to influence and motivate people without direct accountability
• Superior interpersonal, negotiation, influencing and presentation skills are required
• Exceptional strategic thinker, problem solver and decision maker
• Demonstrated knowledge of data management principles

Preferred:

• Project management or business analyst certification

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.