- Lead Care Management, Utilization Management and Health Promotion and Wellness departments for optimal performance against national benchmarks; create a multi-year improvement plan which includes various programs across lines of business (e.g. complex case management and condition support) aimed to sustain a scalable and flexible model aligned with Population Health Management.
- Performs employee management responsibilities to include but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity using lean / Kaizen tools for process improvements.
- Demonstrate strong oversight and discipline related to annual department budgets.
- Coordinate / collaborate with Medical Directors in each Line of Business as job functions relate to care, case, physiologic risk, network, and utilization management in dyad partnerships.
- Collaborate with clinical leadership to engage the enterprise, members, and network physicians to improve total cost of care and member outcomes including operational performance, clinical costs, clinical appropriateness, and authorizations.
- Responsible for leading CM/UM to ensure optimal care supports for priority member populations identified through the strategic work plan and other defined stratification emphasizing continuity of care, in an effort to reduce or eliminate fragmentation, duplication, and gaps in care plans.
- Collaborate with VP of Quality and VP of Pharmacy to support the development, implementation and evaluation of corporate quality improvement programs i.e. NCQA, CMS 5 Star, HEDIS, CAHPS and CCO Quality Incentive Measures.
- Executive sponsorship of Medical Management Platform for CM/UM.
- Develops and deploys disciplined and innovative models of care to deliver high value programs that emphasize cost effective management of CM/UM operations.
- Develop and incorporate performance-enhancing systems and tools for increased automation and efficiency in the scope of work specified for increasing operational excellence (e.g., Machine learning algorithms, ePA deployment, use of bots and Artificial Intelligence to streamline operations)
- Support enterprise-wide total costs of care initiatives.
- Support Quality and Population Health strategies in relation to achieving the growth and profitability goals established across lines of business laid out in enterprise strategic plan.
- Maintain strong and collaborative relationships with the leadership of internal and external stakeholders (e.g., Pharmacy, Quality, Provider Network, IT, Operations, Customer Care, Line of Business and Regional leaders and other identified stakeholders) to address all aspects of CM/UM and total cost of care.
- Actively participate as a key team member in Executive Management Group to ensure successful deployment of the strategic plan.
- Actively participates in various internal and external committees in order to promote and support CM/UM, Population Health, Quality and overall enterprise strategic plan.
- Promote enterprise-wide continuous improvement efforts across teams and demonstrate sufficient knowledge to recognize important synergies and opportunities in clinical outcomes, cost containment, and member satisfaction.
- Excellent analytic, critical, quantitative thinking skills, the foundation for an industry expert and trusted advisor reputation
- Excellent communication skills, ability to build executive level professional presentations (MS Power Point and Visio), creating and managing spreadsheets (MS Excel), managing calendar and email (MS Outlook)
- Responsible for ensuring CM/UM regulatory compliance with National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid services (CMS), and Oregon Health Authority.
- Communicates clear, strategic, and operational direction to ensure CM/UM priorities are aligned with performance standards which include key performance indicators and performance targets focusing on improving healthcare outcomes.
- Meet department and company performance and attendance expectations.
- Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
- Perform other duties as assigned.
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Vice President, Medical Management - Tacoma, United States - PacificSource Health Plans
Description
Job Description Summary
This position is a member of the executive management group and reports to the Chief Medical Officer. The VP of Medical Management is responsible for the Utilization Management (UM) and Care Management (CM) functions for health plan members. This position is responsible for integrating efforts across teams, programs, and improvement activities for all lines of business to promote optimal organizational effectiveness and enhance performance. Key focus on advancing the identification, quantification, and management of risks within scope while improving member experience and outcomes.
Essential Responsibilities:
Supporting Responsibilities:
SUCCESS PROFILE
Work Experience: A minimum of ten years' experience in the health insurance industry with five years in a leadership capacity. Experience and understanding of NCQA, D-SNP model of care standards along with various quality standards. Understanding of CMS, federal/state regulations. Experience in system design, strategic planning in health care operations. Experience managing clinicians.
Education: Health Care professional such as MD, DO, RN, MSW, or PhD. Bachelors' degree required and master's level in Health care or another relevant field preferred.
Knowledge: Knowledge and understanding of disease prevention, medical procedures, diagnoses, care modalities, procedure codes, including ICD-9 & 10 CPT Codes, health insurance and state mandated benefits. Ability to develop, review, and evaluate utilization reports. Knowledge of quality improvement methodology. Knowledge of principles of adult learning and/or motivational interviewing. Experience giving presentations. Good organizational skills with experience in using computers and various software applications including Word, Excel, PowerPoint, Outlook, SharePoint, and audio-visual equipment. Ability to work independently with minimal supervision.
Competencies
Authenticity
Building Organizational Talent
Coaching and Developing Others
Compelling Communication
Customer Focus
Empowerment/Delegation
Emotional Intelligence
Leading Change
Managing Conflict
Operational Decision Making
Passion for Results
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 15% of the time.
