Provides the vision, strategic direction and management of the operations for the market Health Services areas. Manages the improvement of clinical and quality indicators, improving medical cost as well as improving resource utilization in accordance with corporate and market objectives.
- Provides operational and strategic leadership for field clinical programs.
- Provides subject matter expertise to support operations, product development, and growth initiatives.
- Works collaboratively with medical directors and market leadership to deliver clinical programs that support the business objectives.
- Develops value propositions for clinical programs through quantitative analytics, ROI, and evidence-based data.
- Supports corporate Quality Improvement plan and market Quality Improvement plan to achieve target HEDIS results.
- Manages and develops direct reports who include directors and/or managers. Sets direction, allocates, and reallocates utilization of resources as required.
- Determines operational tactics to implement policies and strategies. Establishes reporting systems and controls to ensure compliance with company requirements.
- Provides oversight of and integration with vendors that touch on health service operations and serve market enrollees
- Sets overall goals, performance standards, and operational priorities for one or more functions and manages resources to operational goals and budget.
- Creates a motivated customer-service driven environment.
- Makes recommendations on matters of policy and approve changes in area of expertise.
- Provides leadership, oversight, direction and guidance of operations in Health Services clinical field management. Ensures that activities are carried out in a timely manner.
- Establishes market Health Services clinical management goals, strategy and objectives.
- Develops strategic plans with the ultimate goal to improve the health status of our members, measure outcomes, improve outcomes and subsequently reduce cost, consistent with the corporate and market goals and objectives of WellCare.
- Provides oversight of program analysis, which includes ongoing strategic planning of the clinical management programs.
- Develops and manages activities to ensure compliance with Federal, State, and NCQA accreditation standards.
- Oversees and participates in Performance Improvement Activities.
- Plans annual operating budget and monitors budget performance.
- Manages the development of policies and procedures, ensures implementation and adherence of same.
- Participates in information management and demonstrates proficiency in gathering, and accessing information
- Represents WellCare Health Services at various meetings and conferences on an ongoing basis.
- Recognizes and observes all company and departmental policies and procedures.
- Focuses on achieving departmental and organizational objectives.
- Provides proactive approach and support to emerging business activities established to remain competitive in the marketplace.
- Preforms other duties as assigned.
This position is contingent upon the bid award in the state of Illinois to WellCare Health Plans, Inc.Candidate Education:
- A Bachelor's Degree in Nursing required.
- 10 years of experience in managed care industry required.
- 8 years of experience in Leadership and management, preferably in a managed care environment required.
- Demonstrated expertise in Health Services, such as prior authorizartion, intake, concurrent review, case management, discharge planning including development and management of government programs experience required..
- Solid understanding and leadership experience with managed care quality improvement preferred.
Licenses and Certifications:
- Advanced - Ability to work independently
- Intermediate - Ability to create, review and interpret treatment plans
- Advanced - Demonstrated organizational skills
- Advanced - Demonstrated time management and priority setting skills
- Advanced - Demonstrated leadership skills
- Advanced - Demonstrated written communication skills
- Advanced - Ability to effectively present information and respond to questions from peers and management
- Advanced - Ability to implement process improvements
- Advanced - Ability to analyze information and covert related activities into a comprehensive work plan
- Advanced - Ability to influence internal and external constituents
- Advanced - Ability to represent the company with external constituents
- Advanced - Ability to work as part of a team
- Advanced - Ability to lead/manage others
- Advanced - Knowledge of community, state and federal laws and resources
- Advanced - Knowledge of healthcare delivery
- Advanced - Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
- Licensed Registered Nurse (RN) required.
- Certified Case Manager (CCM) preferred.
- Intermediate proficiency in Microsoft Outlook, Word, Excel, and PowerPoint.
- Intermediate proficiency in a Healthcare Management System.