Provides leadership and oversight of the Field Health Services function and works actively to administer medical policies of care management and clinical support programs. Directs the Field Health Services functions to include establishing, monitoring and achieving operating and financial metrics consistent with regulatory and business requirements.
Additional Responsibilities:Candidate Education:
- Sets regional direction and oversight of Field Population Health Solutions.
- Identifies business process redesign and simplification opportunities to increase efficiency and reduces costs related to medical management.
- Develops and manages activities to ensure compliance with Federal, State, and NCQA accreditation standards.
- Supports and leads a team environment that is results oriented and recognizes individual contribution.
- Set regional priorities, design and update regional work plans assigning responsibilities and holding Directors/VP accountable to achieve outcomes in assigned markets.
- Adhere to staffing budgets, i.e. Workforce Tools/staffing ratios.
- Update and oversee monthly Regional/market KPIs and reports for region.
- Participate in design of MEIs initiatives or PHS Clinical Programs to reduce IP, OP and Physician Costs.
- Hold VP/Directors accountable for designing, implementing and monitoring Corrective Action Plans (CAPs) to reverse trends in markets not achieving results.
- Ensure overall operations of the region is run efficiently and effectively.
- Engage in unified Policy/SOP/JA development and support business standardization across regions.
- Successfully implement/integrate/migrate transferred or new business within the market.
- Support annual evaluation of Regional/market performance by LOB (Medicare and Medicaid) and oversee Trilogy documents/workplan.
- Evaluate regional/market performance by LOB.
- Support continuous improvement of annual employee engagement, manager and culture index, communication and teamwork.
- Support VP/Director/Talent Management- assist in development of plans, guide, and monitor progress, identify opportunities for improvement and resolve quickly barriers.
- Identify and support staff achievements through deserving nominations of candidates for VIP rewards, myRewards and other leadership programs.
- Required A Bachelor's Degree in public health, health administration, business administration, nursing or related field
- Preferred A Master's Degree in public health, health administration, business administration, nursing or related field
- Required 10 years of experience in managed healthcare
- Required 8 years of experience in progressive business management
- Required 7 years of management experience
- Required Other Experience and familiarity with government programs, including Medicare and Medicaid
- Required Other Demonstrated success implementing CMDM/Clinical programs and/or utilization tools/techniques and experience with physician behavior modification
- Required Other Education, training or professional experience in medical or behavioral or clinical practice
- Preferred Other Prior experience with behavior health programs, duals and/or elder-care
Licenses and Certifications:
- Advanced Demonstrated analytical skills
- Advanced Knowledge of community, state and federal laws and resources
- Advanced Knowledge of healthcare delivery
- Advanced Ability to communicate and make recommendations to upper management
- Advanced Ability to effectively present information and respond to questions from families, members, and providers
- Advanced Ability to analyze and interpret financial data in order to coordinate the preparation of financial records
- Advanced Ability to drive multiple projects
- Advanced Ability to lead/manage others in a matrixed environment
- Advanced Demonstrated negotiation skills
- Advanced Ability to implement process improvements
- Advanced Demonstrated ability to deal with confidential information
- Advanced Ability to represent the company with external constituents
- Advanced Demonstrated interpersonal/verbal communication skills
- Advanced Demonstrated leadership skills
A license in one of the following is required:
- Preferred Registered Nurse (RN)
- Preferred Licensed Clinical Marriage & Family Therapist (LCMFT)
- Preferred Other Other Behavioral Health professional licensure
- Preferred Intermediate InterQual
- Preferred Intermediate Other or MCG/Other Clinical Criteria
- Required Intermediate Healthcare Management Systems (Generic)
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Outlook