The purpose of the Parkland Community Health Plan (PCHP) Director of Clinical Investigations is to establish and maintain a robust clinical investigations program of sentinel events, quality of care concerns, member complaints, and allegations of fraud, waste and abuse. Ensures that PCHP understands and complies with applicable laws and regulations pertaining to the Healthcare environment including prevention, investigation and pursuit of quality of care incidents, fraud, waste, and abuse violations. Ensures PCHP's accountability for compliance by overseeing, following up and resolving investigations in partnership with Healthcare Services and state and federal regulations.
Provides oversight and review of the Quality of Care referral, intake and investigation process while giving guidance and direction to team on case investigation steps and actions.
Works with leadership to maintain and revise clinical care policies and procedures, department guidance memos, and educational materials.
Oversees and reviews clinical charts for the following: sentinel events, quality of care concerns, and reportable incidents.
Identifies opportunities for improvement through the investigation process and provide recommendations for process enhancement in order to augment investigative outcomes and performance.
Accurately tracks, reports, and follows up credentialing or peer review concerns, overpayments and recoveries.
Leads required regulatory investigation process and reporting to ensure proper and timely notification of case activity to the appropriate regulatory and/or law enforcement agency.
Tracks and follows all investigation data in addition to robust analysis of trends and patterns.
Identifies and analyzes the design of jobs, work processes, work flows, etc. for the area and implements appropriate changes to improve effectiveness, productivity, and efficiency that support the overall goals of PCHP.
Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure.
Integrates knowledge gained into current work practices.
Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area.
Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements.
Seeks advice and guidance as needed to ensure proper understanding.
Develops and monitors annual budgets that ensure the department has the necessary funds to carry out the goals and objectives that have been established for the department.
Develops, implements, monitors, and revises annual goals and objectives for the department that support the missions and objectives of PCHP. Selects, trains, schedules, motivates, supervises, and evaluates employees making recommendations for disciplinary actions up to and including termination, to ensure maximum utilization of individual and group capabilities.
Ensures that assigned employees receive opportunities to further their knowledge.
Bachelor Degree in Nursing.
Master and/or other advanced degree in Healthcare related field preferred.
Five years' experience in healthcare, managed care investigations or process improvement including NCQA, URAC, CMS, or HHSC required.
Three years' experience in policy development required.
3 years' management experience required.
Experience with federal, state and/or local statutes and guidelines preferred.
Must have Federal Emergency Management Administration (FEMA) course certification for IS-700.B: An Introduction to the National Incident Management System (NIMS) or obtain within 30 days of placement in role.
Must have Federal Emergency Management Administration (FEMA) course certification for IS-100.C: Introduction to the Incident Command System (ICS 100) for Healthcare/Hospitals or obtain within 30 days of placement in role.
Must have Federal Emergency Management Administration (FEMA) course certification for IS-200.HCA: Applying ICS to Healthcare Organizations (ICS 200) or obtain within 30 days of placement in role.
Certified healthcare fraud examiner, LEAN Six Sigma, or process improvement certification preferred.
Skills or Special Abilities
Intermediate Excel, PowerPoint, or Visio skills.
Attention to detail with focused accuracy.
Demonstrated ability to think strategically.
Ability to manage multiple deadlines and time constraints.
Excellent written and oral communications.
Critical thinking and analysis
Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.
Internal Number: A658
About Parkland Community Health Plan
Looking for your next opportunity? If so, choose Parkland and discover what a meaningful job feels like. Whether you work directly with patients or use your talent to support our care, you’ll be part of a team that’s providing valuable health services to Dallas County residents. And here, you’ll have the opportunity to put all your skills to work, and the support to grow and advance in your job and your field. Step into a career that will make a substantial difference for our patients—and for you. We blend cultures, talents, and experience into an exemplary health and hospital system. Parkland has earned distinction as one of America’s Best Hospitals by U.S News and World Report every year since 1994.