Develops and executes clinical strategies for existing and potential expansion markets to develop and implement an industry leading Member Care Experience model and related programs, that supports care goals and delivers improved outcomes for all members. Responsible for development and oversight of programs within the clinical domain of member experience that includes monitoring progress of multi-year strategy to align WellCare clinical program to industry leading practice. Acts as a Subject Matter Expert both within and outside of the organization.
Reports to: VP, Heath Programs & Services
Location: Tampa, FL (Henderson Rd)
- Accountable for the leadership and execution of the clinical components of the member care experience that includes a fully integrated model across physical, behavioral, pharmacy and community/ social
- Drives the development and implementation of long-range plans, goals, and objectives. Directs and coordinates a broad range of activities and functions to ensure effective operations and the achievement of organizational objectives.
- Participates in the development of the clinical model for WellCare, including care management and engagement for all members
- Works with local market Medical Directors and clinical leaders to apply the Integrated Care model best practices models to their populations to include high risk Aged Blind and Disabled, Medicare, and LTC, and TANF members. Refines the care model play book based on evaluation of outcomes.
- Ensures successful implementation of the model of care and best practices including training, auditing, setting staffing ratios, contributing to talent selection when needed and implementing new markets. Partners with field clinical teams to remediate poor performance.
- Develops processes and procedures to ensure department-wide compliance with contractual, regulatory and accreditation agencies.
- Optimizes processes and work flows to achieve successful outcomes and benefit maximization within the scope of responsibility.
- Takes appropriate actions to increase revenue, leverage resources, minimize expenses. Participates in the bid/procurement process to ensure company goals are deployed across the portfolio of businesses and bids.
- Participates in the strategic planning and annual forecasting activities for related to the Care Experience and related clinical teams. Has accountability for assessing market dynamics, competitive position and local market performance against established metrics to meet both short and long term goals for clinical domain
- Builds and enhances relationships with community based partners to support WellCare's mission and create compliant opportunities for growth.
- Establishes department policies and procedures and develops training to support associate and leader development. Develops, monitors and analyzes metrics related to staff productivity.
- Takes the appropriate actions to ensure compliance within all areas of the business for which there is accountability.
- Performs other duties as assigned.
- A Bachelor's Degree in Nursing (BSN), Health Administration, Business or a related field or equivalent work experience is required
- A Master's Degree in a related field is preferred
- 10 years of experience in A health insurance environment with an emphasis in managed care programs is required
- 5 years of experience in Care Management is required
- 3 years of experience in Integrated Care planning and related implementations is required
- Ability to lead/manage others
- Ability to work as part of a team
- Demonstrated interpersonal/verbal communication skills
- Ability to work in a matrixed environment
- Analytical with the ability to drive change
- Must be able to effectively maintain/build relationships across business and/or functional areas
- Demonstrated contributor in a health care or managed care environment.
Licenses and Certifications:
- Required Licensed Registered Nurse (RN)
- Intermediate proficiency with Microsoft Excel, Word, Outlook and PowerPoint is required