Works in collaboration with the Health Plan's Medical Director in developing all clinical strategies, policies and best practices for the assigned Health Plan and its' subsidiaries (Health Plan). Assumes responsibility and authority for establishing, directing, evaluating and coordinating all of the Health Plan's clinical health services activities including utilization management, case management and quality requirements. Directs activities related to developing and administering policy, short and long-range goals, strategic Health Planning initiatives, internal and external reporting and regulatory communication.
Represents and acts on behalf of the Health Plan's President and Medical Director in proposing actions, approving, advising, acting upon and coordinating efforts of all clinical, quality, and health service matters of the Health Plan. Provides administrative direction for the operation of assigned departments and appraises the performance of respective department heads, including the authority to hire and fire subject to the veto of the President. Builds, develops and manages teams capable of carrying out needed initiatives. Communicates routinely with the President, Medical Director, and Quality Improvement Committee concerning health service and clinical policy recommendations and suggested course of action pertinent to the operation of assigned departments. Establishes performance and productivity measures, quality improvement goals and cost controls to maximize resources available. Provides and communicates pertinent information throughout the Health Plan and to the respective governing bodies.
Initiatives and processes are conducted within the scope of broad organizational objectives; requires broad conceptual analysis to define and analyze complex issues and affect optimal solutions. Individual performance is critical to the Health Plan 's success. Recommendations significantly impact the Health Plan 's mission and ability to attain goals.
Responsible to support accreditation for the Health Plan. Implements the quality initiatives of the Health Plan, including employer and State required quality measures such as HEDIS, Consumer Assessment of Healthcare Providers and Systems (CAHPS), Consumer Report Card, etc. Reports to the Board of Directors all member grievances requiring action from the governing board, and state and federal regulatory agencies.
Essential Functions and Responsibilities:
- Establish, direct and monitor policy, procedures, methods, organizational goals and operations consistent with Federal and State laws and regulations, policies and rules, as well as national accrediting organization standards.
- Ensure the Health Plan meets or exceeds all of state and federal compliance requirements.
- Direct, implement and provide short-term and long-term regulatory and applicable clinical reporting to regulatory entities, internal & external constituencies and state and federal regulatory bodies.
- Exercise strategic control over planning short and long fiscal viability for the Health Plan in their respective areas of responsibility.
- Responsible for development and presentation of opportunities to improve health service performance, cost/productivity improvement, cost control, and profitability.
- Develop and implement an annual Quality Improvement program, including evaluation of past performance, determination of specific quality initiatives and on-going utilization analysis.
- Continually assess and evaluate progress toward established internal, regulatory, industry and corporate benchmarks.
- Promote positive relationships with state and federal regulatory/accrediting agencies. Develop and enhance alliances with external groups and associations to promote the reputation of the Health Plan
- Direct all activates to achieve/maintain national accreditation status within Health Services and for the Health Plan.
- Supports, advises, promotes and advocates for staff; provides opportunities for professional and technical growth. Motivates staff; defines priorities and communicates organizational goals and works with them to achieve them; seeks commitment from staff, encourages innovation and team building/planning. Oversees regular staff meetings.
- Translates the Vision and Mission Statement into strategic management interactions with staff and internal and external clients.
- Develop and enhance positive working relationships with MHCC, MIG, the Health Plan senior staff, and associates.
- Display a high level of initiative, effort, and commitment to assuring highest quality output and standards, and continuous quality improvement.
- Display high ethical standards.
- Other duties as assigned or when necessary to maintain efficient operations of the department and the Company as a whole.
Knowledge, Skills, and Abilities:
- Demonstrated persuasiveness in interacting with senior leadership, medical providers, hospital/facility administrators, labor and employers.
- Demonstrated proficiency in strategic Health Planning (ability to think ahead and Health Plan over a 15-year time span).
- Demonstrated proficiency in the ability to reason (ability to apply principles of logical thinking to a wide range of intellectual and practical problems and deal with a variety of abstract and concrete variables).
- Demonstrated strong customer orientation.
- Demonstrated excellent writing and verbal communication and interpersonal skills.
- Demonstrated proficiency in effective decision making.
- Excellent communication, consultancy, facilitation and conflict resolution skills. Exercises sound judgment and diplomacy.
- Communications: communicates verbally and in writing in a positive, consistent, enthusiastic, and open mannered approach with all internal and external customers. Exhibits skill in communicating complex information at a level of understanding for the appropriate intended recipients.
- Decision Making: uses independent judgment to exercise authority on behalf of the Health Plan by keeping the organization's mission, vision, and values at the forefront. Works independently in a self-directed, non-confrontational, collaborative manner.
- Current valid RN License from state the Plan is doing business in.
- Bachelor's degree in business, health care or related field
- Five years experience in a senior leadership role with an HMO or managed care organization with demonstrated managerial experience in establishing and overseeing quality of care programs, financial/utilization analysis.
- Direct interaction with health care providers and regulators.
- Experience and knowledge of HMO, PPO, TPA, PHO and Managed Care functions (e.g. accounting/finance, reinsurance, EDI, case management, marketing, medical delivery, regulatory compliance, claims processing, eligibility, contracting and risk arrangements and actuarial precepts)
- Master's degree in business administration or health-related field
- Ten years' experience in a senior HMO leadership position