Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015. The Vice President Health Plan Clinical Programs works closely and collaboratively with peer Vice Presidents in the Health Plan and other Leaders across the Organization to support the business success of and experience of members in Martin’s Point Health Plans and the integration of Health Plan programs with the Delivery System and external provider partners to ensure mutual success.The Vice President of Health Plan Clinical Programs will be responsible for leading the strategic direction and integration of cost of care, Medicare revenue, pharmacy, and quality programs and operations for Martin’s Point Health Plans. This executive will work closely with all functional areas of the organization (e.g. provider relations, compliance, operations, product management, delivery system, finance) to ensure the successful management of medical expense, revenue, and quality across the Health Plan. The VP works in conjunction with the VP, Health Plan Products and VP, Network Management to ensure the profitability, growth, and compliance of all Health Plan lines of business.
This position provides strategic clinical and operational leadership in the Health Plan for the development and evaluation of systems of health care that improves the member experience and health outcomes, as well as providing stewardship of resources – consistent with Martin’s Point Triple Aim Goals.
- Ensures the integration and the exemplary performance of clinical programs (medical management, revenue, quality, and pharmacy) to support improved care, profitability, and extraordinary member experience for Martin’s Point Health Plans, shared patient/member population and to support expansion into other populations/products
- Institutes processes for continuous evaluation of trends related to medical expense, revenue, pharmacy, quality measure and clinical and operational program performance and identifies and takes acts on opportunities for improvement
- Partners with VP, Health Plan Products to ensure medical expense, revenue, and pharmacy performance supports overall product performance and profitability for Martin’s Point Health Plans and provides support for product development process
- Partners with VP, Network Management to provide strategic support for development of provider payment models and manage cost of care, revenue, clinical and quality improvement through network relationships by providing insights into performance data and collaboration on key programs
- Serves as a strategic partner with Martin’s Point Delivery System leadership to create alignment between medical management, revenue management, quality, and pharmacy initiatives
- Responsible for strategic oversight of the Health Plan medical management program, including medical expense management, utilization management, care/case management, and other clinical programs
- Provides strategic guidance for the development of population-based clinical intervention and measurement of success
- Partners with the Chief Medical Officer in leadership and oversight of the Health Plan Medical Director team, including strategies to manage cost and quality of care
- Responsible for the overall strategic direction of the Medicare risk adjustment program
- Responsible for strategic efforts ensure revenue optimization, including the performance monitoring and continuous improvement to ensure the Medicare program’s profitability
- Responsible for the overall strategic direction and oversight of Health Plan Quality programs and activities, including Star Ratings, HEDIS, NCQA accreditation, and other CMS, DHA, and regulatory/accreditation requirements (e.g. QIPs, Annual Quality Plans/Programs).
- Responsible for oversight of Health Plan Quality committee structure and performance
- Responsible for oversight of member and provider Appeal processes
- Leads strategic efforts for Martin’s Point’s Health Plan and Practice Pharmacy Operations and Clinical Programs, ensuring compliance with DoD, Medicare, and State & Federal Pharmacy requirements and programs address the current pharmacy environment.
- Oversees performance goals for pharmacy programs including pharmacy expense trends, member satisfaction with health plan pharmacy programs, performance of clinical programs, and pharmacy operational performance. Track and analyze performance and advocate for change, where necessary, to meet Martin’s Point’s corporate goals with a strong understanding of its mission to provide superior care and service to its customer base.
- Leads and participates in internal and external committees and forums.
- Build strong relationships with internal and external physicians, clinical care providers and business partners, as well as Health Plan staff.
- Key contributor to strategy development for and execution of new and financially viable products. Provides guidance, leadership and direction to ensure the organization’s strategic plan is translated into tactical goals and expectations that guarantee performance objectives are met or exceeded.
- Maintain an open dialogue with the regulatory/compliance team to ensure the regulatory constituents are satisfied with Martin’s Point’s performance and the organization is compliant with all regulations.
- Review and keep abreast of regulatory changes for USFHP and Medicare programs and ensure proper communication around these regulatory changes.
- Ensure compliance with applicable regulatory and internal requirements, including product reports for the department and other internal or external clients, regulators and accrediting bodies.
- Manage and coach Health Plan management and staff to perform effectively, as a team, to support MP strategies with an intense focus on continuous improvement and proactive problem solving.
- Effectively promotes and manages change, while developing staff to provide leadership to the organization, increase bench strength, including collaboration with staff to develop individual career paths and succession plans.
- Ensures that direct teams are staffed, with individuals that have the appropriate skills and expertise to meet the ongoing business initiatives and creates future leaders and staff bench strength within the team. Strategically aligns resources by continuously planning and organizing to meet initiatives.
- Effectively develop, track, report and communicate metrics to track the department performance against prescribed goals.
- Establish quality control mechanisms for processes and continuously strive to improve operational efficiency through process redesign and data driven evaluation of performance.
- Bachelor degree (MBA or advanced clinical degree highly desirable)
- Clinical licensure preferred (RN, NP, PA, Pharm.D. or similar level clinical licensure)
- 10+ years of related applicable experience with at least three of those years in managed care required
- 8+ years of experience in management and leadership roles
- Demonstrated experience working with Clinicians to deploy best clinical practices
- Knowledge of local provider community (preferred)
- Outstanding presentation, articulation, and relationship building skills are critical
We are an equal opportunity/affirmative action employer.
Do you have a question about careers at Martin’s Point Health Care? Contact us at: firstname.lastname@example.org