Vice President of Care Management, Utilization Management & Operations is a leadership role for the health plan's Medical Affairs department with direct responsibility for the medical activities the department oversees daily including care management and utilization management. Establishes effective programs to address and improve the quality and experiences of our members and continually address the affordability of health care. To this end, it is important for the strategies and tactics to be continuously monitored and reported with metrics to assure opportunities for continuous improvement are maximized.
This role will be instrumental and responsible in assuring all Medical Affairs areas are focused on the four guiding principles; right care, right place, right time, and right cost. This position will be involved in executing and evaluating the Medical Affairs strategic plan as well as participating in the formative process for the future strategic plan. Critical to the success of this position will be the ability to deploy data and metrics to assure care management activities are targeting to be most effective and strongly integrated with utilization and quality activities. The execution of the roles and responsibilities will be accomplished using many tools such as; influencing, collaborating, partnering, negotiating win/win positions, and maintaining strong relationships. Important also to this position will be the ability to blend, link, and collaborate with the leadership of the Utilization function in the Medical Affairs department to maximize the available synergies.
Essential Functions- Executes on the vision and strategic direction for the organization's population health management programs, integrating medical and Behavioral Health, and other services in conjunction with the Chief Medical Officer and Medical Directors.
- Establishes indicators for monitoring and evaluating the quality and appropriateness of care/service, assessing for continuous improvement in monitored indicator activities, monitoring member satisfaction, and directing initiatives for improvement and evaluating the effectiveness of interventions across the continuum of care to members. -MCR is a key Performance Metric
- Maintains liaison for clinical quality initiatives and works to establish and promote a culture of clinical and operational excellence.
- Assures Medical Affairs compliance across regulatory and accrediting areas.
- Develops the annual operating and capital budgets to sufficiently meet departmental needs and ensures that department stays within budget and accounts for variances.
- Demonstrates analytical skills in organizing, planning, and development of long range strategic and tactical plans for population health management.
- Monitor medical management services industry to ensure the organization's services remain competitive and even are a differentiator in the industry. Works in strong collaboration with all other Priority Vice Presidents to assure maximum understanding and synergies
- Build and maintains strategic partnerships to maximize the value of services delivered to members and families through effective, efficient, safe, and high-quality patient centered care.
Qualifications - Bachelor's Degree or equivalent Clinical. Required
- Master's Degree or equivalent Master's or PhD. Preferred
- 10 years of relevant experience leadership experience. Required
- Registered Nurse (RN) - State of Michigan. Required
How Corewell Health cares for you- Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
- On-demand pay program powered by Payactiv
- Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
- Optional identity theft protection, home and auto insurance
- Traditional and Roth retirement options with service contribution and match savings
- Eligibility for benefits is determined by employment type and status
Primary LocationSITE - Priority Health - 1231 E Beltline Ave NE - Grand Rapids
Department NameExecutive Medical Director - PH Managed Benefits
Employment TypeFull time
ShiftDay (United States of America)
Weekly Scheduled Hours40
Hours of Work8 a.m. to 5 p.m.
Days WorkedMonday to Friday
Weekend FrequencyN/A
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