The Senior Vice President, Managed Care is responsible for directing, managing, and leading PMA Companies' Managed Care Department. This includes maximizing every opportunity to provide appropriate, quality care while addressing workers' compensation medical and pharmacy utilization and cost data at a granular level. PMA's Managed Care programs include: Network Solutions, Bill Repricing and Negotiation, Clinical Solutions, Pharmacy Solutions, Business and Customer Support and Business Analytics. This role also supports Old Republic's Third Party Administrator (TPA) operations by ensuring Managed Care services, pricing approaches, and program performance align to TPA client needs and growth objectives.
Responsibilities
- Maintain a comprehensive, fully integrated Managed Care model:
- Operate a Clinical Management Program which leverages Utilization Review, specialized RN units and technology
- Deliver Pharmacy Solutions which include formulary management, nurse specialists, intervention programs aimed at cost reduction & avoidance, fraud, waste and abuse
- Maximize the impact of networks and bill review solutions by leveraging core and specialty networks supported by complex internal review and negotiation units
- Increase the utilization of qualified providers and leverage customized panels and preferred networks
- Ensure the model continues to evolve based on the assessment of performance/results, industry developments and jurisdictional changes.
- Oversee relationships with business partners, regularly engage them and assess their performance.
- Provide ongoing leadership while executing and achieving strategic objectives:
- Develop annual business plan objectives that align with our corporate goals
- Ensure ongoing communication and collaboration with other departments such as Claims, Underwriting, Information Technology, Customer Service Center as well as leadership in our field offices and our client-facing staff
- Partner with TPA Leadership to support implementation, service delivery, issue resolution, and ongoing performance reporting for TPA clients utilizing Managed Care programs
- Maintain a plan for the Managed Care supervisory and management team that includes appropriate delegation, accountabilities, succession planning, strategic thinking and tactical execution
- Serve as PMA's Managed Care expert and a thought-leader within the Old Republic organization and industry
- Demonstrate the ability to effectively articulate a vision for Managed Care and the department's impact on PMA's goal of being a premier provider of workers' compensation insurance and services
- Effectively balance strategic, tactical and operational items while applying technology and automation where practical
- Monitor staffing, service levels and departmental performance throughout the year. Validate and/or adjust priorities, structure and inter-departmental initiatives as needed
- Ensure Managed Care programs leverage system capabilities and improve quality outcomes while reducing overall cost
- Develop revenue and expense strategies, financial objectives, and competitive pricing approaches and track profits and losses by product for both our insurance and TPA operations, including support for TPA client growth, retention, and service commitments
- Develop Business and Customer Support and Analytics
- Leveraging data and analytics to identify actionable and measurable intelligence when profiling providers, monitoring vendor partners and assessing internal performance
- Provide information and analysis to Claims leadership aimed at improving performance and compliance with Managed Care programs
- Expansion of educational initiatives to increase internal ownership and knowledge of Managed Care programs and drive product utilization
- Provide internal and external client support in the areas of RFP responses, sales tactics and support and account metrics
- Ensure that appropriate documentation, implementation and communication of established policies, procedures and operating standards is completed
- Department engagement with internal and external audiences
- Demonstrate commitment to Company's Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards and laws applicable to job responsibilities in the performance of work.
- Bachelor's degree is required, Master's Degree is preferred.
- A background in nursing (RN) is preferred.
- CPCU, CCM, CMAC, CDMS designations are preferred.
- A minimum of 10 years Managed Care experience within the workers' compensation industry, with at least 5 years in a Managed Care leadership position is required.
- Demonstrated management and leadership skills with a proven track record of successful group dynamics and interpersonal relationships.
- Adept at working collaboratively with cross-functional business units to achieve organizational objectives.
- Strong influencing skills.
- Experience in strategic planning and execution with the ability to analyze and propose solutions to complex business challenges and problems.
- Strong customer service orientation.
- Ability to analyze and propose solutions to business challenges and problems.
- Professional written and verbal communication, interpersonal skills and the ability to work with others.
- Ability to prioritize and organize.
- Willingness to travel for business purposes and remain visible at industry functions in order to develop and maintain solid relationships.
