Drives and formulates the business strategies and operational plans for the Medicare line of business within a large single state or smaller multi-states to ensure growth, market positioning, compliance and profitability goals are met or exceeded. Spearheads the profit and loss oversight of designated geographic segments including sales, local medical management, quality improvement initiatives, network contracting and provider relations. Works closely with the Medicare, COO, Medicare CFO and other executive team members to define, align and influence business strategies and drivers. Focuses on systematically improving operational execution and efficiency to ensure the region delivers on promises to key stakeholders. Ensures continual assessment of Medicare opportunities and challenges within assigned geographic segment. Ensures compliance with all relevant state and federal contracts and regulations.
Our ideal candidate will have experience in Medicare & P&L. Ability to travel 50% .
Reports to: SVP, Division President
Dept.: Health Plan Services
Location: Remote or based at one our locations
- Leads and directs the day-to-day operations of the Medicare health plan for assigned state(s). Sets and executes the overall Medicare market strategies, goals and objectives, and financial performance.
- Provides direct management of network development, provider relations, quality improvement, community advocacy, medical management and sales and marketing.
- Provides direction on the Medicare market product and growth strategies.
- Drives and manages financial performance and takes appropriate actions to increase revenue, leverage resources, manage and/or minimize expenses and ensure compliance with all business and administrative regulations.
- Develops the annual budgets and presents budgets for approval.
- Manages and drives quality initiatives aligned with continuous performance improvement towards STAR outcomes.
- Oversees the development, implementation and continuous evaluation of the utilization and quality management program for medical services delivered by contracted health care providers.
- Oversees the development and maintenance of a compliant, competitive provider network to ensure health care needs of Medicare members, and advances value based provider partnerships.
- Develops provider contracts and manages provider partnerships to achieve quality and cost management objectives. Works closely with providers to enhance relationships to maximize their ability to effectively manage the cost of medical delivery.
- Oversees the development and implementation of short and long term sales and marketing plans.
- Provides leadership to ensure strong collaboration between the state(s) and centralized shared services resources
- Supports the Medicaid business development on any Medicaid opportunities that may be presented in the assigned states(s)
- Performs other duties as assigned.
- Required A Bachelor's Degree in a related field
- Preferred A Master's Degree in a related field
- Required 10 years of experience in overall managed care, business management/operations, health plan finance, provider network management or managed care consulting
- Required 3 years of management experience in functional leader positions
- Required Other Strong experience engaging external constituents to identify mutual goals, develop solutions, make decisions, and achieve desired outcomes
- Required Other Strong experience fostering relationships with state legislative and regulatory entities, national trade bodies, CMS and other industry groups
- Preferred Other Experience with multi-site profit and loss accountability
- Preferred Other Experience in Medicare managed care programs
- Advanced Ability to analyze and interpret financial data in order to coordinate the preparation of financial records
- Advanced Ability to communicate and make recommendations to upper management
- Advanced Ability to influence internal and external constituents
- Advanced Ability to represent the company with external constituents
- 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
- Advanced Ability to analyze information and covert related activities into a comprehensive work plan
- Advanced Ability to implement process improvements
- Advanced Ability to work within tight timeframes and meet strict deadlines
- Advanced Demonstrated analytical skills
- Advanced Demonstrated negotiation skills
- Advanced Demonstrated organizational skills
- Advanced Demonstrated written communication skills
- Advanced Demonstrated leadership skills
- Advanced Demonstrated interpersonal/verbal communication skills
- Advanced Demonstrated problem solving skills
- Advanced Knowledge of community, state and federal laws and resources
- Advanced Knowledge of healthcare delivery