Operational Leader - Program Director-Clinical Operation

Operational Leader - CMS WISeR Program Clinical Operation

We are seeking an experienced Operational Leader to oversee clinical operations for the CMS Wasteful and Inappropriate Service Reduction (WISeR) Model implementation in New Jersey. This role will be responsible for managing all operational aspects of our participation in this innovative six-year Medicare demonstration model ), which focuses on reducing fraud, waste, and abuse through technology-enabled prior authorization processes for select medical services.

The WISeR Model is a CMS Innovation Center demonstration program that implements prior authorization processes for select medical services to reduce fraud, waste, and abuse while maintaining quality patient care.

Key Responsibilities

• Lead day-to-day operations of the WISeR program clinical workflows in New Jersey
• Ensure compliance with all CMS requirements and model specifications
• Develop and implement operational protocols for prior authorization review processes
• Manage vendor partnerships for Business Process Outsourcing (BPO), mail room operations, and print services
• Oversee third-party vendor performance and service level agreements
• Coordinate logistics for document processing, mail handling, and printing requirements

Required Qualifications

• Bachelor's degree required;
  Master's degree in Healthcare Administration, Business Administration, or related field preferred
• Minimum 7 years of healthcare operations management experience
• 3+ years of experience with Medicare programs, prior authorization, or utilization management
• Previous experience with CMS demonstration models or innovation programs preferred

Technical Skills

• Strong understanding of Medicare fee-for-service operations and regulations
• Experience with prior authorization systems and clinical decision support tools
• Proficiency in healthcare data analysis and reporting systems
• Knowledge of fraud, waste, and abuse detection methodologies
• Familiarity with electronic health records and healthcare technology platforms
• Experience with automation technologies, AI/ML platforms, and process optimization tools

Leadership and Management

• Proven track record of leading cross-functional teams in healthcare settings
• Experience managing complex operational initiatives with multiple stakeholders
• Strong project management skills with ability to meet strict deadlines
• Change management experience, particularly in implementing new clinical processes

Regulatory Knowledge

• Deep understanding of Medicare regulations and compliance requirements
• Knowledge of CMS Innovation Center models and demonstration programs
• Familiarity with healthcare quality measures and reporting requirements
• Understanding of New Jersey healthcare regulations and market dynamics

Preferred Qualifications

• Experience with the specific services covered by WISeR (skin substitutes, electrical stimulators, orthoses)
• Background in clinical operations for durable medical equipment or specialty services
• Previous participation in CMS alternative payment models or demonstration programs
• Professional certification in healthcare management (FACHE, CHAA, or similar)
• Experience with artificial intelligence, machine learning, or robotic process automation in healthcare
• Background in digital transformation and automation implementation
• Knowledge of automated decision-making systems and clinical algorithms

We are an equal opportunity employer and welcome applications from diverse candidates.