PLADS Clinical Director

Job Summary

Responsible for research, development, and selective implementation of clinical initiatives, training, and projects within the Medical Department, and often serves as a liaison with operational units of Aflac. Provides oversight and training for all clinical protocols and best practices used by the Absence Management clinical staff. Responsible for developing clinical processes and procedures for clinical case management. Oversees the best practice protocols of the clinical reviewers for STD, FMLA, LTD, and/or disability pension business

Principal Duties & Responsibilities

Develops and maintains clinical case management best practices for absence management, leave administration, and return to work protocols and workflows; develops and manages the development and training for Absence Management clinical staff, including Registered Nurses, Behavioral Health Clinicians, and Vocational Rehabilitation Counselors; identifies opportunities to enhance existing guidelines and procedures; acts as a liaison between operational areas and the Medical Department on guideline issues; monitors guideline compliance and identifies solutions to improve on deficiencies

Ensures efficient and effective clinical case manager staffing models, oversight of clinical audits, and clinical case management training and mentoring with new clinicians and existing team; collaborates with the Clinician Manager during the recruitment and hiring of new clinician candidates; supports Claim Operation Program Managers on account specific clinical issues as needed; collaborates with Clinician Manager regarding clinical case managers’ performance

evaluations related to quality audits, adherence to best practice protocols, and ensuring clinicians meet or exceeds performance guarantees for clients if applicable

Provides quality control audits of clinician reviewers and develops improvement initiatives/trainings and best practices based on findings in coordination with Medical Director; provides oversight and enhancement of clinical audit tool for performance assessment of clinicians; develops clinical metrics to assess efficiency of individual case management activities by clinician; coordinates quality improvement initiatives within the Medical Department, and in collaboration with the Aflac product managers

Oversees external medical judgment service vendors and performs regular audits with reports for the Medical Director; ensures that work product content and clinical rationales are well-reasoned, and reports are timely based on contracted best practice turn-around-times; coordinates regular service review meetings with vendors and serves as a liaison to Operational units

Develops complex case analysis and research for issues requiring Medical Director attention/intervention; provides preliminary evaluation and recommendations on enhancement of clinical best practices and protocols which includes development of new training material and process flows as applicable

Leads the development of internal clinical education for new and existing clinicians e.g. case management basics, medical terminology, using MD Guidelines, etc., and manages the education programs for both clinical and non-clinical staff, e.g. CDMS and ADMS, respectively; responsible for developing clinical processes and procedures for clinician review and co-management which includes, but is not limited to, documentation standards, process workflows, scripting, and clinical correspondence; develops and provides oversight and training on all clinical protocols and best practices used by the Medical Department including Registered Nurses, Masters & Doctoral level Degreed Behavioral Health Clinicians, and Vocational Rehabilitation Consultants

Coordinates Medical Department’s educational initiatives, such as lunch-and-learns and complex claim reviews through coordination of clinical content with Claims and Appeals departments; develops medical bulletins/advisories for company-wide dissemination on selected clinical issues; assists in developing, planning, and execution of training programs and may serve on internal advisory committees as applicable

Serves as medical department liaison for regulatory and accreditation initiatives requiring department's support; serves as the primary resource for RFPs where clinical case management practices are in question; participates in high profile sales meetings and site visits requiring detailed knowledge of clinical best practices and medical knowledge (travel required as needed)

As later determined, may be responsible for all Absence Management clinicians, RNs, Masters Level Clinician, and other clinical team members to include, but not limited to, performance management, managing day to day team duties, and hiring for the clinical team

Performs other related duties as requested by manager

Education & Experience Required

Bachelor's Degree in Health care or a related field

Active Non-restricted Health Care License in US Nursing, Medicine, Behavioral health care or other healthcare related field

6-8 years of clinical experience

5-7 years of disability experience which can include Worker’s Comp experience

1-year clinical case manager experience

1-year clinical case manager experience

Applicable Certifications, CCM, CDMS, COHN, (Preferred)

Applicable Board Certifications: American Academy of Nurse Practitioners, American Board of Disability Analysts, American Board of Medical Specialties, American Board of Physician Specialties, etc. (Preferred)

Master's Degree or Doctorate In healthcare or a related field (Preferred)

Or an equivalent combination of education and experience

Job Knowledge & Skills

• Case Management - Proficiency Level Expert

• Clinical Policies and Standards - Proficiency Level Advanced

• Knowledge of Claims - Proficiency Level Basic

• Medical Claims Administration - Proficiency Level Expert

• Medical Ethics - Proficiency Level Advanced

• Customer Focus - Proficiency Level Advanced

• Effective Communications - Proficiency Level Advanced

• Insurance Legal and Regulatory Environment - Proficiency Level Basic

• Knowledge of Insurance Industry - Proficiency Level Intermediate

• Knowledge of Organization - Proficiency Level Intermediate

• Customer Interaction - Proficiency Level Advanced

Competencies

Acting with Integrity - Clearly states goals and beliefs; lets people know his/her true intentions; does what he she said they would do; follows through on commitments

Communicating Effectively - Expresses ideas and information in a clear and concise manner; tailors message to fit the interests and needs of the audience; delivers information in a manner that is interesting and compelling to the listener

Pursuing Self-Development - Demonstrates ambition and desire to move forward in his/her career; engages others in discussions about career development; seeks feedback on ways to increase his/her performance; takes advantage of opportunities to build new skills and capabilities

Serving Customers - Builds strong relationships with customers; stays aware of customer needs, concerns and satisfaction; responds promptly to customer questions and requests; effectively manages

Supporting Change - Enthusiastically participates in new change initiatives and programs; focuses on reasons why changes will work and how they will be beneficial

Supporting Organizational Goals - Actively supports organizational goals and values; demonstrates enthusiasm toward the company's goals and mission; aligns actions around organizational goals

Working with Diverse Populations - Shows respect for the beliefs and traditions of others; encourages and promotes practices that support cultural diversity; discourages behaviors or practices that may be perceived as unfair, biased, or critical toward people with certain background