It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

Under the direction of the Vice President of the Senior Vice President of Behavioral Health, the Senior Director of BH Clinical Programs oversees the BH Care Management, BH Utilization Management and Clinical Programming teams. The Senior Director develops and integrates the strategies to enhancing the quality of care for patients, satisfaction, healthcare outcomes in a cost effective manner and ensures integration with the physical health teams. Additionally, the Senior Director is responsible and accountable for the overall strategic direction oversight, analysis, clinical compliance and data reporting for all products and in all markets. The Senior Director ensures that the delivery of care management and related care coordination activity is based on specialized clinical expertise, critical thinking, established protocols, policies, procedures, practice standards, and applicable contract and regulatory care requirements. The Senior Director ensures a compliant quality based utilization management program. The Senior Director is responsible for the development of and ongoing improvement in, standardized clinical decision making in accordance with the appropriate state and federal coverage determinations, product benefits, internal medical policies and InterQual criteria . The senior director also works in collaboration with the Senior Director of Strategy and Operations, the BH Medical Director, the Senior Vice President of BH to determine the most effective measures to improve quality of care and reduce TCOC through analysis of over and under- utilization. The Senior Director is accountable for the continuous assessment of the clinical program effectiveness and is responsible for identifying opportunities for improvement, assessing risk and communicating observations, recommendations and results. Additionally he/she will lead the BH clinical programming team which will provide BH clinical support to members identified by call center and other areas throughout WellSense and develop clinical programming to support the BHUM and BHCM teams. The Senior Director represents the Plan in external meetings with key customers, in particular regulatory and advocate stakeholders

Our Investment in You:

* Full-time remote work

* Competitive salaries

* Excellent benefits

Key Functions/Responsibilities:

* Oversees WellSense's BH care management program, BH UM program and BH Clinical Support Program to include
processes, operations and functions in all markets and for all products

* Ensures compliance with contractual, regulatory and NCQA requirements and standards

* Participates in implementation of key program initiatives such as improved BH / Medical Integration

* Provides strategic guidance on complex member issue resolution impacting Plan business. Works with OCA BH team to
ensure consistency between products and markets at an operational / programmatic level by ensuring oversight
infrastructure is in place consistent with regulatory contractual obligations in order to best support strategic initiatives and
priorities.

* Analyzes data from multiple sources to identify and respond to trends and / or emerging issues

• Demonstrate a passion for leading positive change by continuously improving and defining innovative care management interventions, keeping the team continuously informed about mandates, regulations, and best practice innovations.
• Promote best practice in impacting social determinants of health and homelessness and help to establish a framework for continued objective evaluation of the interventions.
• Promote standardization of workflows, policies and documentation to ensure that there is a solid data base from which to report and evaluate the BHCM program.
• Promote continuing education and professional development for each staff member in an individualized manner.

* Provides leadership to ensure best utilization of resources in obtaining organizational goals, regulatory compliance, adhering
to corporate policies through oversight of daily operations, assessment of adequacy of staffing, and adherence to standards
of care management and UM

* Utilizes metrics and reports to ensure work is allocated timely, appropriately and meets regulatory compliance requirements,
member needs, and performance standards

* Collaborates cross-functionally with internal stakeholders, (customer service, marketing, sales, product, finance, utilization
management, pharmacy, behavioral health) and external stakeholders to ensure operational requirements are facilitated to
support care management and utilization management

* Develops, implements and evaluates departmental policies, processes and procedures that ensure efficiency, effectiveness,
quality and consistency and meet regulatory requirements.

* Develops and monitors performance and quality metrics, including audits and call monitoring. Escalates if performance falls
below expectations, and works with leadership to develop a plan to improve performance.

* Proactively identifies opportunities to improve existing processes or add new processes and recommends/proposes solutions
to improve outcomes across the department. Anticipates downstream impacts of workflow/ process changes to BH
department and other departments in the end to end process.

* Works to ensure the timely and accurate production of regulatory and contractual reporting

* Acts as a liaison to Legal, Compliance and Quality Department on issues that have both legal risk and compliance aspects and
coordinates with the Accreditation Manager on NCQA audits as well as being responsible for all corrective actions in assigned
area.

Supervision Exercised:

* Oversees directly and indirectly up to 30 clinical and non-clinical staff

Supervision Received:

* Supervision is provided weekly

Qualifications:

Education Required:

• Master's Degree in a Behavioral Health Discipline or the equivalent combination of training and experience is required.

Experience Required:

* 8 + years of related experience in a behavioral health setting with a minimum of 3 years' experience in a managed care
setting

* A minimum of 7 years of progressive clinical leadership experience within managed care of a similar health care environment

* A minimum of 7 years of experience successfully managing people and leading teams

* Experience using data and metrics to monitor performance, allocate workloads, and monitor medical and utilization trends

* Experience managing projects, programs, complex change initiatives, and/or CMS and EOHHS audits and regulatory
compliance

* A minimum of 7 years of experience in developing and executing strategic business plans and budgets with a track record of
achieving results

* Experience work with an integrated care model/use of supportive services

* Experience in program development and/or health policy.

* Experience in managing remote and field teams.

Experience Preferred/Desirable:

* Expertise in clinical/care management information systems such as Jiva

* Experience managing teams in Medicare, Medicaid and duals program

* Experience leading transitions of care programs and familiarity with community resources and advocacy programs

Required Licensure, Certification or Conditions of Employment:

* Independent BH licensure (LICSW, LMHC, Ph.D., Psy.D., RNCS, etc)

* Successful completion of pre-employment background check

Competencies, Skills, and Attributes:

* Effective collaborative and proven process improvement skills.

* Strong oral and written communication skills; ability to interact within all levels of the organization.

* A strong working knowledge of Microsoft Office products.

* Demonstrated ability to successfully plan, organize and manage projects

* Detail oriented, excellent proof reading and editing skills.

* Excellent demonstrated Clinical Skills.

* Proven ability to building strong teams that apply their diverse skills and perspectives to achieve organizational goals

* Strong oral and written communication skills; develop and deliver messages consistent but fined tuned for different
audiences; communications that convey a clear understanding

* Ability to maneuver comfortably through complex policy, process and people-related organizational dynamics.

* Knowledge of accrediting organizations such as NCQA, and of InterQual protocols, HEDIS and other quality measures.

* Knowledge of federal Medicaid, EOHHS and DHHS regulations, guidelines and standards.

* Demonstrated ability to think strategically; see ahead to future possibilities and translating them into breakthrough
strategies

* The ability to bringing people together to leverage their skills, talents, and knowledge to achieve a common purpose.

* Create synergy-resulting in a combined effort with greater results.

Working Conditions and Physical Effort:

* Fast paced office environment

* Occasional travel may be required.

* Work is normally performed in a typical interior/office work environment.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.