- Leads the development and implementation of clinical operations policies and procedures. Creates and maintains a strong compliance culture with the clinical team.
- Strategically aligns the clinical program, compliance standards and financial goals and monitors quality and performance to goals on a regular basis.
- Creates a clinical operations work environment that fosters collaboration, growth and development, and a member centric focus on clinical excellence in service.
- Grow and develop a clinical team in operations, financial acumen, utilization management, risk adjustment, HEDIS and STARs program.
- Drives performance in closing HEDIS/STARS gaps, Risk Adjustment gaps, clinical program improvements.
- Manage processes to meet member population needs.
- Provide oversight of utilization management/care management health plan related delegated function reporting activities.
- Work across departments to provide support and guidance on what can be done within each department to help meet performance metrics, such as closing HEDIS/STARS gaps, RA gaps, etc.
- Help build daily practices for the Clinical Operations team that help drive key metrics.
- Help make key decisions that are driven off of data and help support Provider Relations staff, so that we can impact Cost, Quality, and STARS/HEDIS, with a boots on the ground effort.
- Participates in executive meetings to bring the clinical operation needs into alignment with business goals.
- Addresses obstacles and challenges to achieving goals proactively and adjusts operations accordingly.
- Maintains audit readiness, by ongoing training, competency assessment, audit, monitoring of metrics and corrective action.
- Oversight of UM Process, while maintaining CM/DM functions in house.
- Other duties as assigned.
- Master's Degree in a health affiliated or business affiliated field.
- 8+ years of relevant professional experience required and knowledge of medical management clinical review processes.
- 5+ years of managerial experience.
- 5+ years of Medicare health plan experience.
- Comprehensive knowledge of managed care industry standards and government regulations.
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VP of Clinical Operations - Boston, United States - eternalHealth
4 weeks ago
Description
eternalHealth – Your Forever Partner in Healthcare and Beyond
Healthcare is confusing, but it doesn't need to be. A consumer-centric HMO based in Boston, MA, we are a tech-focused start up that is committed to creating long-lasting partnerships with our members, our providers, and you
About the role: As VP of Clinical Operations Care with eternalHealth you will be a core member at eternalHealth management team. The VP provides oversight for development of strategies and processes, direction of staff, and execution of clinical operational tasks. This position will work towards meeting financial and operational performance goals and standards.
We provide a unique opportunity to be a part of a health plan in its beginning stages, and you will have insight into all the operations and expertise that is required to run a successful and sustainable plan as well as build the foundation for the sustainable growth that will be crucial to eternalHealth's success. Our team members are flexible and able to play different roles, while staying committed to teamwork and collaboration, and passionate about sustainable change.
Responsibilities:
Requirements:
Working with eternalHealth: eternalHealth is an Equal Opportunity Employer which means that we are committed to upholding discrimination-free hiring practices. As a woman-led company,
and one committed to diversity at all levels, we strive for an organization of inclusion and
acceptance. We are changing healthcare for the better, starting with our own diverse and
passionate teams. As an eternalHealth employee you will be empowered to contribute to our teams and strategy, regardless of previous healthcare experience. Our valued team members
are encouraged and expected to offer new solutions and creative input, all while keeping in line with eternalHealth's mission, values, and compliance standards.
Accommodations: Any eternalHealth applicant will be considered based entirely on their individual qualifications. Should you require reasonable accommodations during the application process (which may include a job-related assessment) please contact us separately; email with the email subject "Reasonable Accommodations – Applicant Name
Here".
