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Position Summary
The Director of Health Plan Clinical Programs provides strategy and program development for clinically and financially successful Utilization and Care Management programs for Senior and Military family populations. This person will work closely with the Health Plan Clinical leadership team and provide oversight and coordination of a team providing care management related activities and will monitor clinical and financial outcomes for the Martin’s Point Health Plan. The Director will work closely with VP of Health Plan Clinical Program and the Health Plan Medical Director to ensure the clinical departments can support enterprise-level growth, CMS STARS performance, clinical outcomes, and medical trend targets. This includes creating new or redesigning existing product programs to achieve the triple aim. The Director will lead a team to execute on program strategy, design and implementation through project management, and the ability to foster support for program enhancements across all levels of the organization. Partnering with all Health Plan and shared service departments, the Clinical Programs Director will support the above through coordination of government and regulatory affairs, industry best practices and innovation, national evidence-based medicine guidelines, population health strategies and clinical integration.Job Description
Key Outcomes:
- Implements of new programs and services to meet population health needs including activities to manage medical costs with focus on health outcomes.
- Develops objectives across the department to ensure compliance with professional and regulatory standards, federal contracts, and accreditation standards.
- Develops and leads high performing care management activities to reduce cost per capita for all member populations while ensuring members receive high value care and support in the healthcare system for optimal health outcomes.
- Leads complex care and care management activities for Martin’s Point to improve clinical and medical trend outcomes. Determines needs for specific disease programs and implementation, such as CHF.
- Oversees operational and outcome reporting to monitor the progress and outcomes of all care management and disease management activities carried out by the department including reporting to regulatory and accrediting agencies.
- Manages relationships and coordination with external vendors and delegated entities. Responsible for Delegation Oversight of Clinical vendors
- Develops and manages Key Performance Indicators (KPIs) for care management and disease management.
- Partners with cross functional teams to successfully enhance existing clinical program’s structure to address the needs of members, support the work of care teams, promote high STAR performance and align with our company objectives.
- Ensures all program design and redesigns are in compliance with professional and regulatory standards, federal contracts, and accreditation standards.
- Collaborates across health plan clinical programs as well as other key health plan departments and the delivery system to ensure alignment of clinical and operational initiatives and activities.
- Collaborates with the Director Health Plan Quality to support initiatives such as HEDIS, Member Safety, QIPs, QII’s, CMS Stars and accreditation.
- Collaborates with clinical teams across Health Management synthesizing clinical outcome drivers and quality/operational requirements into an aligned program, strategy to deliver high-impact clinical outcomes, client value and business results.
Education/Experience:
- Bachelor’s degree in a clinical field of study (RN, Pharmacy, etc.); Master’s degree in nursing or related field preferred
- 10+ years of experience in health care including experience in a managed care Medicare plan, care management/ disease management, utilization management and prior authorization.
- Demonstrated operational excellence with a history of development, implementation and management of a health plan clinical program strategy, design, redesign, clinical platform conversions, implementation, and evaluation.
- Experience using data and data analysis to design programs, manage care coordination services, and manage success of programs.
- Strong project management experience required.
- Experience in Medicare Advantage and TRICARE preferred.
Required License(s) and/or Certification(s):
- RN, NP, PA, PharmD or similar level of clinical licensure
Skills/Knowledge/Competencies (Behaviors):
- Broad knowledge of managed care and health plan functions; Medicare Advantage required; USFHP and/or TRICARE knowledge is a plus
- Demonstrated project management skills overseeing complex projects in matrix environment.
- Strong attention to detail and the ability to multitask.
- Excellent communication and presentation skills, oral and written.
- Demonstrates an understanding and alignment with Martin’s Point Values
- Knowledge of NCQA/URAC accreditation as well as CMS requirements, and State and Federal regulations
- Knowledge of Medicare Advantage regulations, CMS Stars, and HEDIS.
- Knowledge of reimbursement models, utilization patterns, and quality improvement opportunities
- Strategic ability to see the big picture and lead a team through change
- Ability to operationalize a concept
- Strong organizational skills including the ability to work independently and prioritize work.
- Ability to review, interpret and present information to Health Plan Leadership and external partners.
- Ability to lead change and assist in the development of change strategies in support of Health Plan and Organizational goals and objectives.
- Competence with computers and business applications; Microsoft Excel, Word, PowerPoint, Outlook, Access.
- Excellent written and verbal communication skills with the ability to write executive reports and power point presentations as well as the ability to present findings in internal and external settings.
There are additional competencies linked to individual contributor, provider and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.
We are an equal opportunity/affirmative action employer.
Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org