The Clinical Consultant provides clinical and operational support as a U.S. Healthcare Subject Matter Expert, providing various clinical support services and operational guidance for business processes, to include Case Management, Utilization Management, Clinical Coverage Preservice, Claims and Appeals review, Clinical Support and Notification, Inpatient Care Management, and Pharmaceuticals. This position will serve as Clinical Consultant to all Clinical Operations businesses, anticipating clinical needs and developing solutions that enhance clinical knowledge and clinical decision-making skills among frontline nurses. Solves complex problems while developing innovative solutions that meet business needs and supports implementation of those solutions among clinicians throughout the business operation. Assesses business education needs and develops clinical training programs to support a wide variety of clinical projects and educates employees on clinical foundation topics via in person and online training platforms. Utilizes appropriate clinical resources and guidelines, which include, but are not limited to U.S. (United States) state and federal mandates, national and local coverage determination, applicable internal UnitedHealthcare medical policies, formularies and updates, as well as, coverage determination guidelines, such as Milliman and InterQual.
Responsibilities and Accountabilities
Operational Management Functions:
- Collaborates with Solutioning and Transitions on new business needs: demo, staff profile, training content, timelines
- Assesses learning needs of individuals and teams within clinical business processes
- Develops learning goals, objectives, curriculum, and measurements that promote desired performance outcomes
- Creates and delivers complex clinical foundation content using adult learning principles and strategies with business consideration
- Leverages learning technologies and tools for presentation, collaboration, and engagement
- Facilitates and manages learning in web-based and/or face-to-face environments
- Reviews evaluative data to make improvements and/or establish new initiatives and business improvement solutions.
- Maintains updates to curriculum and assessments based on changes and relevant feedback
- Establishes positive working relationships with all levels of staff and management
- Provides coaching, guidance, and feedback to learners
- Monitors new LOB until reaches steady state and conducts LOB Transition Support
- Provides Clinical Refresher and Upskilling Training for all LOBs as needed
- Conducts clinical acumen assessments during hiring and Attrition Review Support as needed (for non-RN led teams)
- Anticipates customer needs and proactively develops solutions to meet them.
- Serves as a key resource on complex and/or critical issues.
- Performs complex conceptual analyses to solves complex problems while developing innovative solutions
- Reviews work performed by others and provides recommendations for improvement
- Assesses and interprets clinical education needs and requirements for all businesses
- Works with minimal guidance; seeks guidance on only the most complex tasks
- Coordinates with others to develop program or process implementation plans
- Works in a virtual team environment
Performance Management Functions:
- Communicates and collaborates with operations managers and business partners to improve production quality and efficiency, develop best practices, and identify clinical process issues
- Provides explanations and information to others on difficult issues
- Identifies skill, knowledge, and certification requirements for program/process implementation, based on requirements
- Initiates a quality driven approach to identify root cause and process improvement opportunities
- Communicates and collaborates with key stakeholders, regarding findings and recommendations
- Develops an understanding of clinical and clinical support business needs (e.g., through process walk-throughs, audit findings, survey results, case reviews or additional research, etc.)
- Performs, assists with, or oversees clinical quality audits
Staff Development Functions:
- Coaches, provides feedback, and guides others
- Provides subject matter expertise to train others on clinical foundation topics
- Supports implementation of business strategies
- Develops talent in all levels to establish strong talent pipeline through education, training, and coaching
- Collaboratively works with Business Operations Manager to coordinate for training new hires, ensuring clinical foundation training timelines are met within agreed expectations
Reporting:
- Develops program/process tools and resources, based on communication and education requirements
- Identifies technology needs to support programs/processes (e.g., systems for use of the program)
- Obtains input and feedback from stakeholders during communication development
- Communicates educational progress and status of training programs with stakeholders
Educational and Licensure Requirements
Active unrestricted US Registered Nurse license in at least one US state or jurisdiction
Bachelor of Science in Nursing
Active Philippine Registered Nurse license
Work Experience Requirements
Minimum of 3 years clinical nurse experience in U.S. healthcare system
Strong knowledge of medical terminologies and U.S. healthcare processes
Proficient in creating power point presentations and excel documents
Demonstrates effective verbal and written communication skills
1-2 years clinical BPO process experience in Inpatient Clinical support, Case Management or Utilization Management (preferred)
1-2 years experience training and/or educating Registered Nurses (preferred)
Knowledgeable in Microsoft Office
Additional Preferred Qualifications
- MCG or IQ trained/certified
- Certification in Case Management or Managed Care
Skills Attributes Desired
- Strong clinical acumen and awareness of the US healthcare system
- Servant Leadership style that collaborates well and is team-focused
- Works independently, taking the initiative to act with strong self-management skills
- Displays calm under pressure with good control over emotional responses and self-control during times of adversity, conflict, and change
- Superior interpersonal/communication skills and able to communicate with large teams
- Strong listening, verbal, and written communication skills
- Strong training delivery techniques both for instructor led face to face or virtual training
- Able to prioritize multiple tasks and ensure all are monitored and tracked to completion
- Strong organizational skills and multitasking abilities
- Technical aptitude and proficiency with good analytical and decision-making skills
- Strong capability on digital content creation, curriculum design and use of MS Office 365 apps and tools
- Value integrity and comply with company's regulations and policies
- Able to provide clear directions and set specific expectations
