Director Of Clinical Operations

Personify Health

About The Position

Ready to create a healthier world? We are ready for you! Personify Health is on a mission to simplify and personalize the health experience to improve health and reduce costs for companies and their people. At Personify Health, we believe in offering total rewards, flexible opportunities, and a diverse inclusive community, where every voice matters. Together, we’re shaping a healthier, more engaged future.

Requirements

Basic computer literacy
The ability to work on multiple screens, and proficient typing skills.
Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook Excellent verbal and written communication skills
Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as the ability to understand and interpret complex information from others.
Ability to work independently and utilize written resources to solve problems.
Teams on and off camera, SharePoint, Drives as needed, VPN, UM Web or Health Notes, El Dorado, Quick Links, GIAS, ADP, Confluence, Phone system with headset, Smartsheet—there may be additional programs as it relates to job duties
Knowledge of medical claims and ICD-10, CPT, HCPCS coding
Excellent verbal and written communication skills for upward and downward conversations
Microsoft Office and other computer skills and ability to learn and help guide software development
Flexible and able to prioritize day-to-day position requirements
Strategic thinking with proven ability to communicate a vision and drive results
Proficient in analysis and interpretation of clinical data
Comfortable with multiple accountabilities and matrix management
Proven record of strong relationships and working with diverse teams
Demonstrated ability to work independently with excellent judgment
Strong interpersonal skills necessary to effectively communicate with medical personnel and members
Analytical and problem-solving skills necessary to identify and review pertinent information
The ability to incorporate analytical data into new or existing clinical programs to enhance quality of care
Ability to maintain an extremely elevated level of confidentiality
Able to successfully handle competing priorities
Experience in the Utilization Review Process which includes Prior-Authorization/Pre-Certification, Retro Reviews, Concurrent Reviews and Post Service Claims Review
Experience in disease management and know and understand disease progression
Knowledgeable of the Federal, State and ERISA regulations
Associate Degree of Nursing plus 3 years mgt. experience and/or Bachelor Degree of Nursing RN
Licensure in California required.
Minimum 5 years of Utilization Review, Case Management, Chronic Disease Management, and/or Hospital experience required.
Minimum 3 years of compliance related experience preferred.
Experience working in sales, with groups, Medicaid, Medicare, fully insured, HMO and Self Insured preferred
Managed Care management experience preferred in UR, CM, DM
Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards.
Ability to maintain regular, punctual attendance.
Ability to sit for 6-8 hours.
Ability to travel throughout the United States and external countries.
Constant use of computer keyboard and mouse; repetitive use of both hands.
Occasional to frequent twisting of neck; occasional bending of neck and at waist.

Nice To Haves

Master’s degree of Nursing preferred
Certification in Case Management or Utilization Review a plus.

Responsibilities

Responsible for the overall clinical aspects of the Care Management Team.
Supervise Utilization Review (UR), Chronic Disease Management (DM) and/or Case Management (CM) team personnel including participating in interviewing, hiring, and training employees; plan, assign, and direct work; appraise performance; rewarding and disciplining employees; addressing complaints and resolving problems.
Keep team informed of clinical updates, compliance related issues and policies.
Work with the VP of Care management to establish work procedures and processes that support company and departmental standards, procedures, and strategic directives.
Use appropriate judgment in upward communication regarding department or employee concerns.
Maintain and improve UR, DM, and CM teams operations by monitoring system performance; identify and resolve problems; audit and analyze staff performance; prepare and complete action plans; assist in managing system and process improvement and quality assurance programs as it relates to clinical management and plan language interpretation.
Oversee the negotiation and implementation of cost management strategies to affect quality outcomes and reflect this data in monthly case management reviews as it relates to clinical aspects.
Ability to meet productivity, quality, and turnaround times daily.
Ability to pass external audits to include URAC and NCQA.
Maintain HIPPA compliance per company’s policy and procedures.
Maintain confidentiality and minimum requirement rules.
Complete all required yearly training per company’s expected period.
Ability to communicate with external sponsors and vendors and to communicate clearly about the programs that are offered by the company internally and externally.
Ability to create, teach and present information to internal and external audiences with varying backgrounds and cultures

Benefits

Comprehensive medical and dental coverage through our own health solutions (yes, we use what we build!)
Mental health support and wellness programs designed by experts who get it
Flexible work arrangements that fit your life, not the other way around
Retirement planning support to help you build real wealth for the future
Basic Life and AD&D Insurance plus Short-Term and Long-Term Disability protection
Employee savings programs and voluntary benefits like Critical Illness and Hospital Indemnity coverage
Professional development opportunities and clear career progression paths
Mentorship from industry leaders who want to see you succeed
Learning budget to invest in skills that matter to your future
People Matter: Inclusive community where every voice matters and diverse perspectives drive innovation
One Team One Dream: Collaborative environment where we celebrate wins together and support each other through challenges
We Deliver: Mission-driven work that creates real impact on people's health and wellbeing, with clear accountability for results
Grow Forward: Continuous learning mindset with team events, recognition programs, and celebrations that make work genuinely enjoyable
Competitive base salary that rewards your success
Unlimited PTO policy because rest and recharge time is non-negotiable
Benefits effective day one—because you shouldn’t have to wait to be taken care of