The incumbent will be responsible for the successful delivery of the Integrated Health Home Program. This includes ensuring that each member in the Medicaid population will be linked to an Integrated Health Home provider based on their level of need and the provider's ability to meet those needs. The incumbent will be accountable for monitoring the performance and compliance of participating providers and ensuring that the program is operated in accordance with state guidelines and regulations.
Department: Exec State
Reports to: Director - Value Based Partnerships
Location: Phoenix, AZ
Additional Responsibilities: Candidate Education:
- Responsible for the delivery of the IHH Program.
- Responsible for provider education, serving as a resource for providers who have questions or require assistance with the program.
- Monitors performance and compliance of participating providers.
- Manages reimbursement and incentives for improved IHH provider performance.
- Works with Clinical leadership and ancillary care teams to ensure the program adheres to state clinical guidelines and regulations.
- Serves as the escalation point for program concerns and questions from participating providers and works with internal cross functional staff as well as provider staff to resolve issues and create risk mitigation plans.
- Ensures providers comply with State requirements including technical and staffing requirements and performance on quality measures.
- Facilitates partnership between WellCare, State and Providers deploying a variety of assessment approaches to ensure compliance on a broader set of requirements, incentives and sanctions to drive changes in the case of underperformance.
- Responsible for escalating well-formulated issues and risks to leadership and effectively communicates business and technology issues and solutions.
- Assists in program-level reporting and leverages results to increase program visibility and to proactively monitor performance. Responsible for reporting program progress to all levels of the organization.
- Supports the successful enrollment of members into IHHs and/or the transfer of members and medical records between Integrated Health Homes.
- Participates in contract negotiations with healthcare partners to ensure expectations are established and maintained through the duration of the program.
- Responsible for proactive risk management that may affect provider participation in the program. Assists in strategic analysis of potential business and/or operational opportunities as needed.
- Monitors IHHs’ performance on care delivery, providing IHH’s with necessary input to support the development of individual plans of care, and ensure that members have access to covered services.
- Performs other duties as assigned.
- Required A Bachelor's Degree in Healthcare, Nursing, Business or related field
- Required 3 years of experience in Clinical program development and management
- Required Other Skilled in managing provider-facing (e.g., physician, hospital, etc.) communications, and or, provider relations.
- Preferred Other Experience with a major network development with healthcare partners and hospitals
Licenses and Certifications:
- Advanced Ability to work in a matrixed environment
- Advanced Demonstrated interpersonal/verbal communication skills
- Intermediate Other Strong facilitation and presentation skills
- Intermediate Other Ability to analyze and interpret health data in order to coordinate the creation of specific care programs.
- Intermediate Other Demonstrated program management skills
A license in one of the following is required:
- Preferred Other One of the following licenses is preferred : RN, BSN, LSW, LCSW, MSW, LCPC, LPC, LCMHC
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Outlook
- Required Intermediate Microsoft PowerPoint
- Required Intermediate SharePoint
- Required Intermediate Microsoft Word
- Preferred Intermediate Other Various Care Coordination Programs & Reporting Tools.