Clinical Operations Specialist

General Information

Position Purpose

We are looking for an individual who has a passion for healthcare, project management, and performance improvement. The Clinical Operations Specialist supports clinical operations by developing deep and meaningful connections with provider partners, helping to develop scorecard metrics, assisting the team in abstracting specified clinical data through medical record review, and providing best-in-class member support, swiftly handling incoming inquiries from members. The role will focus on the following key areas:

Practice improvement: The Clinical Operations Specialist must have an understanding of the goals and objectives of population health and clinical operations as well as a broad understanding of data, workflows and systems. The Specialist will be responsible for proposing processes for clinical and process improvement, helping our provider partners achieve quality targets, and finding opportunities to contain the total cost of healthcare for our stakeholders. The role requires a strong understanding of value-based contract parameters to ensure all clinical foci are aligned with contract requirements. This includes regularly travelling to local, in-network hospitals and physician practices to share performance updates as well as assisting the clinical operations team with medical record reviews to improve contract performance.

Provider education: The Clinical Operations Specialist will assist with all provider education needs including, but not limited to, metric specification documents, suggested workflows, coding guides, informational videos and handouts, and ad hoc education needs. The Specialist will gather and share information regarding performance on clinical metrics and develop strategic plans to roll out improvement strategies specific to practice needs. The Specialist will work with leadership on corrective action plans with poor performing practices.

Care coordination: The Clinical Operations Specialist will develop relationships with community and network partners to learn key workflows, processes and solutions in order to help navigate healthcare for our members, inspire and engage members to accomplish their best health, and optimize members’ experience. The Specialist may spend a large portion of workdays on telephonic interactions.

Essential Job Functions

• Conducts regular provider visits to educate providers and office staff on topics including clinical network operations, preventive and quality metrics, and risk adjustment.
• Synthesize complex data sets and reports to prepare meaningful materials relevant to various stakeholder groups.
• Establish strong relationships with provider offices and conduct analysis for resolution of provider concerns.
• Compile information from medical records, internal reports, and other resources while maintaining confidentiality according to established privacy standards.
• Gains clear understanding of criteria for compliance with clinical quality measures.
• Ensures a high degree of accuracy of information entered.
• Make and receive telephone calls to/from members after emergency room visits, hospitalizations or other triggering events and address their health or insurance-related questions, make follow up appointments, connect them to community resources, and inspire them toward health and wellness.
• Address incoming member calls and inquiries.
• Be able to learn the basics of health insurance plans and effectively communicate the details to members when needed.
• Accurately document and track your work on trackers and other internal tools.
• Develop mission related materials and present to stakeholder groups including wellness platform clients, employer groups, and other stakeholders with clarity and confidence.
• Manage multiple projects at once and be able to balance numerous stakeholders’ opinions and priorities.
• Light housekeeping (shared by all employees).
• Protect Monument’s value by keeping information confidential.
• Review systems and processes and suggest/make modifications to address issues.
• Occasional travel is required for conferences and assignments.
• Perform other related duties as necessary for thee purpose of ensuring the efficient and effective functioning of the organization.

Knowledge, Skills, Abilities, and Other Characteristics

• Two to five (2-5) years working in healthcare provider or in a health plan setting.
• Must have a minimum of two years’ experience in customer service (telephonically or in-person) in any field that you believe can be translated to this role.
• Clear-thinker, problem solver, ability to “get things done”.
• Ability to develop and manage relationships.
• Strong communication skills, especially verbally (i.e. by phone).
• 2+ years of experience in Google G-suite and/or Microsoft Office Suite.
• Reliable transportation and valid and current drivers license and auto insurance.
• Experience in process engineering, program development, data/analytics, clinical operations and/or member services preferred.
• Healthcare experience in care coordination or discharge planning preferred.
• Passion for advocacy and ability to motivate others preferred.
• Ability to manage multiple tasks at one time and move quickly from one project to another preferred.
• Brings a high degree of professionalism preferred.
• Able to accept feedback in the spirit of growth and continuous improvement preferred.
• Must adopt and live the Monument Health core values.

Education and Certifications Requirements

Baccalaureate degree required, with a preference in health related study or business. Clinical education or other relevant clinical licensure in the State of Colorado preferred.

Monument Health Overview

Monument Health, LLC is a joint venture capitalized in 2015 and owned by Intermountain St. Mary’s Regional Medical Center and Primary Care Partners. Monument Health facilitates the largest and most comprehensive clinically integrated network (CIN) on Colorado’s Western Slope and delivers high-impact population health services. The high performing integrated network and population health services allow for better, more coordinated care and cost containment in the communities it serves.

Monument Health currently manages a network of 100,000+ members across the Western Slope, encompassing Commercial, Medicaid, CHP+, Medicare, Medicare Advantage, and Dual Special Needs (D-SNP) insurance plans with multiple payors. Self-funded employer groups may also utilize the Monument Health network and population health services on their TPA platforms. In addition, Monument Health offers analytics, population health and employee-based wellness programs and services.

Physical Aspects of the Job – Regularly Required to Perform Job Tasks

Physical Requirements 

Lifting Requirements

Working Environment

Vision Requirements

Hearing Requirements

Mental Requirements

OSHA Category Classification: Category III

The normal work routine of this position does not involve exposure to blood, body fluids, or tissues. The person holding this position will not be called upon to perform or assist in emergency medical care or first aid or to be potentially exposed in some way. Category III does include handling of implements, utensils, equipment; using public restrooms and public telephones; and personal contacts such as handshaking.