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Leads development of health plan clinical programs and operations through collaboration with leaders and external partners to optimize quality based clinical outcomes, utilization management metrics and meet state and Federal requirements for target populations and related programs. This individual is responsible for partnering with the Medicaid and Medicare Product Organization to support Medicaid new business development activities as well as re-bids, in additional to Medicare benefit and program design related to clinical programs. This individual operates within the medical management structure as a liaison to the Population Health Solutions organization for alignment of program goals and reporting on clinical and financial outcomes. This role builds consensus on program designs; facilitates feedback on clinical performance; and participates in on-going quality improvement processes.
Collaborates with Product and Business Development teams to lead clinical program development initiatives to support new business and re-procurement efforts.
Develops clinical programs that are reflective of industry best practices and achieve market leading results in improving outcomes and reducing costs, while meeting the specific state and Federal program requirements. Delivers reports to internal stakeholders for evaluation, feedback and influence on program development or change.
Through population health management strategic approaches develops and monitors deployment and performance of clinical programs (i.e. maternity program, complex care program, critical gaps in Care programs, LTSS program, etc.)
Leads initiative based business and clinical program owners in assessment of program performance and improvement strategies.
Evaluates program design and deployment plans for adherence to regulatory or contractual requirements.
Maintains knowledge of competitive activity and program designs.
Communicates to accreditation and delegation stakeholders program design, implementation status and performance metrics, as well as, quality improvement project details.
Works with local Medical Directors and network leadership to establish healthy provider relationships and communication channels.
Provides an external voice within key industry groups on integrative health programs.
Perform other duties as assigned.
Additional Responsibilities:Candidate Education:
Required A Bachelor's Degree in a related field
Preferred A Master's Degree in a related field MPH, MBA, PhD, or MD
Required 5 years of management experience Healthcare or managed care settings
Required 5 years of experience in Clinical program design and/or implementation and/or accreditation or quality management oversight
Required 5 years of experience in Knowledge of Medicare and Medicaid benefit designs
Required 5 years of experience in Business plan development, written and verbal presentations
Advanced Other Solid understanding of statistical analyses, clinical study methodologies and outcome based measures
Advanced Ability to communicate and make recommendations to upper management
Advanced Demonstrated written communication skills
Intermediate Demonstrated analytical skills
Advanced Demonstrated time management and priority setting skills
Advanced Ability to influence internal and external constituents
Advanced Ability to implement process improvements
Advanced Ability to work in a fast paced environment with changing priorities
Advanced Ability to work in a matrixed environment
Advanced Ability to lead/manage others in a matrixed environment
Advanced Demonstrated project management skills
Licenses and Certifications: A license in one of the following is required: Technical Skills: