Job DetailsJob LocationMain Office - Santa Barbara, CA
Position TypeFull Time
Job CategoryMedical Management
DescriptionCA Central Coast Salary Range: $164,689 - $247,034
Job SummaryThe Director of Dual Special Needs Clinical Programs is a strategic operational leader with deep experience leading clinical operations. The position reports to the Health Services Officer (HSO) and is pivotal in developing, launching, and managing CenCal Health's D-SNP Care Management clinical programs by 1/1/2026. This role ensures strict adherence to CMS and DHCS D-SNP regulations and spearheads ongoing enhancements to the Care Management Program. The Director of Dual Special Needs (D-SNP) Clinical Programs is a seasoned expert in D-SNP program management, driving continuous improvements in healthcare delivery.
This position is responsible for managing staff and the day-to-day clinical operations related to the D-SNP product line including the monitoring of related delegated entities. This position is responsible for overseeing the development of quality, effective programs that enhance the members' experience, access to care, improve their well-being, and provide continuity of care, while decreasing care fragmentation and adhering to regulatory requirements. The Director of Dual Special Needs Clinical Programs holds responsibility for CenCal Health's D-SNP Utilization and Care Management programs and ensures the integration of Behavioral Health to support whole person care.
Duties & Responsibilities- Provide leadership and strategic direction to Medical Management leadership team and larger clinical organization.
- Develop the "trilogy" documents (program descriptions, annual workplan, annual workplan evaluations) for Utilization Management, Care Management and Disease Management programs, and ensure appropriate integration of Behavioral Health into relevant programs and documents.
- In collaboration with the Health Service Officer and cross functional team, develop and monitor CCH's Model of Care and evaluate performance. Lead the process to determine if off cycle changes to the MOC are required and lead the process to file the MOC on the required routine basis.
- Develop and ensure delivery of performance goals for all areas of responsibility.
- Develop key performance indicators to monitor performance and adjust as needed to address needs and trends across Utilization Management, Care Management and Disease Management.
- Active leadership and accountability to develop and deliver D-SNP initiatives and programs within Medical Management.
- Develop and execute a strategic roadmap to optimize talent, processes, and technology.
- Ensure operations are efficient, effective, and provide value to members and provider community.
- Develop standard operational processes and procedures that promote quality, compliance, and consistency.
- Collaborates with the Health Services Officer (HSO) and cross-functional teams to develop and implement the Medicare Care Management program, ensuring alignment with organizational goals and objectives.
- Leads the development of Medicare Care Management (MCM) policies, procedures, and workflows to support effective care management, risk stratification, and member engagement.
- Provides guidance and support to care management teams in the implementation of MCM requirements, including annual assessments, care plan interventions, interdisciplinary care teams and all UM functions.
- Collaborates with IT/Reporting to develop regulatory and operational reporting.
- Oversees the collection, analysis, and reporting of MCM-related data and performance metrics and provides regular updates to senior leadership.
- Collaborates with Quality Improvement and Population Health teams to support initiatives.
- Serves as the primary point of contact for internal and external stakeholders regarding MCM-related inquiries, audits, and compliance issues.
- Stays informed about changes in CMS regulations, guidance, and best practices related to MCM, and ensures timely implementation of required updates.
- Leads training and education initiatives to increase awareness and understanding of D-SNP requirements among care management teams and other stakeholders.
- Drives continuous operational improvement in processes and outcomes through data-driven analysis, benchmarking, and best practice sharing.
- Develop and execute talent strategy to support growth and development of leaders and team within the D-SNP department.
- Develop and drive programs and initiatives within the D-SNP department, and actively engage in organization-wide projects as a collaborative partner.
- Provide leadership and strategic direction on vendor partnerships.
- Collaborate with the Quality Officer to develop and support Quality Improvement Programs.
- In collaboration with direct report team and with input from the HSO, develop and execute an engagement strategy that promotes communication, active participation, accountability, growth, and development.
- Responsible for ensuring CenCal Health meets all MCM regulatory and licensing requirements.
- Develop and maintain understanding of applicable regulatory initiatives, requirements and industry trends related to Utilization Management, Care Management, Disease Management, and quality improvement to evaluate impact on organization; and develop plans for program changes as indicated; support regulatory compliance; participating on committees as appropriate.
- Fiduciary responsibility for department costs, as well as supporting reserves. Prepare annual department budget plans, monitor expenses, and document variances from approved budgets.
- Ensure departmental readiness for all CMS, DHCS, DMHC, etc. audits.
- Represent and support CenCal Health's benefit decisions at administrative hearings as needed.
- Prepare reports and make presentations at various internal quality committees and occasionally to the governing board.
- This position works collaboratively with Claims, Member Services, Provider Services, Legal, Quality, Behavioral Health, Pharmacy, and other departments, as well as the COO and Chief Medical Officer (CMO) to educate, train and implement effective medical management operations.
- Other duties as assigned.
Motivates others to create extraordinary results, and unite people to turn challenges into successes by embracing 'The Five Practices of Exemplary Leadership' of The Leadership Challenge:
1. Model the Way- Clarify values by finding your voice and affirming shared values.
- Set the example by aligning actions with shared values.
2. Inspire a Shared Vision- Envision the future by imagining exciting and ennobling possibilities.
- Enlist others in a common vision by appealing to shared aspirations.
3. Challenge the Process- Search for opportunities by seizing the initiative and my looking outward for innovative ways to improve.
- Experiment and take risks by consistently generating small wins and learning from experience.
4. Enable Others to Act- Foster collaboration by building trust and facilitating relationships.
- Strengthen others by increasing self-determination and developing competence.
5. Encourage the Heart- Recognize contributions by showing appreciation for individual excellence.
- Celebrate the values and victories by creating a spirit of community.
QualificationsKnowledge/Skills/Abilities- Experienced leader and operator in leading clinical operations; utilization management, case management, disease, or population management.
- Current working knowledge of the California Medi-Cal program and CMS and DHCS D-SNP program.
- Experience building high performing teams.
- Experience leading operations through change and increasing employee engagement.
- Strategic mindset with ability to execute and deliver results.
- In-depth knowledge of Medicare and Medi-Cal regulations as it relates to D-SNPs, including MCM requirements, and experience with CMS audits and compliance activities.
- Strong project management skills, with the ability to lead cross-functional teams and drive initiatives to completion.
- Excellent communication and interpersonal skills, with the ability to collaborate effectively with stakeholders at all levels of the organization.
- Analytical mindset with the ability to interpret data, identify trends, and make data-driven decisions.
- Commitment to quality, patient-centered care, and continuous improvement.
- Certification in Case Management preferred.
Education & Experience- Bachelor's degree in nursing, Healthcare Administration, Public Health, or a related field or an equivalent combination of education and experience.
- Minimum of 5 years of experience in healthcare, with a focus on D-SNP and care management.
- Certification in Case Management (CCM), Certified Professional in Healthcare Quality (CPHQ), or similar credentials preferred.
- Experience working with non-profit organizations, such as COH's health plans.
- Experience with Policy and workflow development and implementation.
