This position serves as the leader forclinical operations within the Health Management Department serving members from both the Uniformed Services Family Health Plan (US FHP) and Medicare Advantage. The Director has primary responsibility to carry out all care coordination services for Martin’s Point’s Health Plans, including those described in the Program Description. Accountabilities include allclinical operations,processes, programs, policies, procedures, documentation andreporting. Additionally, the Director participates with the Vice President of Health Plan Clinical Programs, Health PlanMedical Directors, Director Health Plan Quality, and other leaders throughout Martin’s Point to develop programs thatsupport the success of all components of the Triple Aim. Care coordination activities include but are not limited to: health promotion and prevention, pre-admission planning,utilization management, discharge planning, transitions of care, case management, disease management and condition specific programs. Additionally, the Health Management Division provides expert clinical review of complexclaims, reconsiderations and benefit interpretation issues or questions. This key leadership position works collaboratively with several other departments across the organization, including the Martins Point Health Care medical practices and external Network providers.
Key Outcomes and Primary Accountabilities:
Ensure tactical implementation of the Care Coordination Program through and by:
- Modeling behaviors consistent with Martin’s Point leadership attributes
- Staying apprised of industry best practices in all operational areas of the department
- Using LEAN leadership and process principles to build and maintain standard work, drive continuous improvement, manage through metrics, and ensure goal achievement
- Providing a personal example of professional practice, demonstrating excellence in the care coordination process, including identification, engagement, assessment, care planning, intervention and evaluation.
- Maintaining focus on the improvement of health outcomes through strategy and collaboration.
- Leading care coordination activities to reduce the cost per capita for all member populations
- Leading care coordination activities and oversight for Martin’s Point’s Special Needs Plans (SNPs), including but not limited to oversight of Model of Care development and execution, care coordination contact point and care plans, and provider training and coordination
- Maintaining an extensive understanding of reimbursement models, utilization patterns and quality improvement opportunities.
- Proposing and planning new programs and services to meet population health needs, client expectations, and marketing strategies and to manage cost of care.
- Articulating the vision for the department and motivating staff to strive for that vision and ensuring the department’s goals and strategies align with the organization’s vision and strategy
- Collaborating with other departments and divisions to integrate health care financing and delivery, creating measurable health care value
- Participating in external professional organizations and committees
Oversee the operations of the department by:
- Developing annual department specific goals and objectives, care coordination goals, quality management plans and the department budget.
- Overseeing all project plans, action plans and budgets to ensure goals are met
- Establishing consolidated management reports to monitor the progress and outcomes of all care coordination activities carried out by the department.
- Developing, implementing and ensuring continuous quality improvement and process re-engineering to deliver effective and efficient programs and services
- Ensuring all programs are documented through policies, workflows and manuals
- Ensuring adequate technology solutions and data management to support operational functions and to optimize efficiency
- Managing the relationships and coordination with external vendors and providers (e.g. health coaching, disease management, third party administrators, etc.)
- Collaborate with Director of Quality to support quality initiatives including HEDIS, Member Safety, QIPs, and others and providing data and information to identify ongoing quality initiatives.
Provide oversight, support and mentoring to department staff by:
- Setting and communicating department goals and expectations
- Promoting professional development of the entire department through example, coaching, talent management, and training.
- Managing performance issues in a timely and constructive manner
- Participating in Health Plan and Organizational Committees and Work Groups as needed
- Ensure department compliance with professional and regulatory Standards, federal contracts, and accreditation standards.
- Minimum of 8+ years of health care experience with 4+ years of leadership experience in a managed care setting, preferably in commercial and Medicare Advantage Plans
- Experience overseeing utilization management, case management and disease management required
- Bachelor’s degree in nursing with a Master’s degree in nursing or related field strongly preferred
- Experience using data and data analysis to design programs, manage care coordination services and measure success strongly preferred
- Experience managing external relationships with vendors, clients and physician partners strongly preferred
- Experience with health program strategy, design, implementation and evaluationpreferred
- Experience applying CMSA, URAC and NCQA standards as well as State and Federal regulations preferred
- Strategic ability to see the big picture and lead a team through change towards a vision
- Demonstrated ability to proactively develop and implement new programs or services based on data and benchmark analysis
- Strong project management experience and the ability to operationalize a concept
- Proven ability to establish department work plans, goals and manage to those objectives
- An effective team builder and leader with a track record of integrating functions and fostering a positive work environment that motivates staff to achieve their potential
- Strong track record of building internal and external collaborative relationships
- Demonstrated ability to develop proactive and innovative solutions to improve process effectiveness
- Demonstrated ability and desire to coach employees and develop staff through training, stretch assignments and constructive feedback
- Broad understanding of medical management and population health management programs as well as how these programs operate most effectively.
- High level understanding of health information systems including care management support systems and informatics used to plan, design and evaluate impacts of programs