The Vice President of Medical Director Operations drives improvements in the efficiency and quality of workflow, technology, and other initiatives that impact the medical director team. In addition to maintaining the highest quality of work, special focus is to ensure that work reaching the medical director team is organized, compliant, and appropriate for physician review. The executive partners with the SVP Utilization Management to improve naviHealth’s post-acute model of care. This role, in collaboration with Executive Medical Directors, is accountable for guiding standardized, high quality, clinical and non-clinical medical department operations across national and regional Health Plan segment partners. This executive leads the strategy to improve/maintain the medical department’s operational quality during the rapid scale of current Medicare Advantage operations across the US. Additionally, this executive leads the development of the medical director infrastructure to support additional lines of business. This role includes collaboration with the solutions and product teams to successfully implement current efficiency initiatives and identify additional innovative opportunities.
The VP, Medical Director Operations manages large teams of physician personnel and additional support staff. This role has operational oversight over physicians who are responsible for completing pre-service and continued stay medical necessity reviews and aligns with the SVP of Utilization Management and Executive Medical Directors to ensure the delivery of the highest-quality provider and patient experience. The ability to manage a physician team to drive consistency in the delivery model is an absolute must for success in this role. At the same time, this executive needs to understand regional and national market nuances to support those relationships. Maximizing resource efficiency, minimizing practice variation, and continuing to scale MD operations while keeping the patient and provider at the center of the work are a few of the important contributors to success in this role.
This leader works alongside Strategy and Transformation leadership to drive and support advanced operational initiatives such as the application of advanced automation technology and implementation of clinical and operational algorithms. The VP of Medical Director Operations also aligns with other VPs of UM operations to ensure delivery of a seamless and financially responsible post-acute care experience for patients and providers. This individual also is also responsible for collaborating with finance to support KPI projections, staffing and budget year over year.
This executive’s performance is essential to driving naviHealth’s ability to successfully meet compliance & contractual obligations for partners/CMS/NCQA, as well as meeting ADK financial targets.
- Lead the Medical Director team and operational functions related to the delivery of the naviHealth business.
- Drive operational improvement strategies, allowing for delivery of patient-centric, financially responsible and compliant utilization management services conducted by the medical director team.
- Execute and deliver on key strategic program objectives for the MD Operations area.
- Collaborate with other UM Operational VPS to ensure operational effectiveness and efficiency of organizational appeals and denials.
- Support UM product/geographic expansions driven by variation across Commercial, Medicaid, and Medicare.
- Collaborate with senior leadership, other operating areas of the company, and Strategy and Transformation to continue to evolve naviHealth’s clinical operating model to more efficiently deliver the best possible outcomes for the patients we serve.
- Provide exemplary customer service across all Health Plan clients.
- Assist in driving standardization of the clinical care management processes and delivery across all market contracts and teams.
- Assist in driving efficiencies and efficacy within the core lines of business.
- Create clinical and corporate processes to include workflows, product designs, personnel structure.
- Manage course setting and execution of team growth and development.
- Support effective management of diverse, geographically dispersed, Health Plan clients.
- Drive accountability to performance standards and quality standards across the medical director team.
- Act as a direct liaison to Clinical Quality, Compliance, and Regulatory functions within our Medical and Health Services Organizations.
- Ensure compliance with all federal and state regulations, accreditation organizations and SLAs.
- Establish meaningful and relevant sub-metrics to further enable assessment of medical director team against goals.
- Ensure the timely reporting of Contractual UM parameters (SLA) monthly or as otherwise defined to the health plan and market leaders.
- Support Medical Directors in the understanding of health plan KPI and variation in metrics impacting performance.
- Ensure best practice operational and clinical processes are functioning across the Organization to ensure appropriate care determinations.
- Partner with Health Services, under the direction of the SVP, to create clinical stakeholder engagement with market leadership and other key levels of the firm, interfacing when necessary with client partners, and provider organizations to achieve common goals.
- Collaborate with the central Appeals/Denials team, market leadership and medical directors to achieve effective business processes to optimize operational metrics and maintain fidelity to the clinical model.
- Proactively model and manage staffing needs in conjunction with team leaders and Executive Leadership.
- Foster a positive culture within their team and support professional development of direct reports.
- Travel requirements: 10 - 20% of time
- Perform other duties and responsibilities as required, assigned, or requested.
- Bachelor's degree in business, healthcare administration or related field required; Master's degree preferred
- 10+ years of experience in operations management, preferably in a healthcare setting
- 5+ years of experience leading and building effective teams
- Experience leading and building physician teams
- 8 - 10 years of direct or indirect experience with health plan UM operations
- Licensed clinician preferred
- Strong leadership skills demonstrated by the ability in leading large teams of individuals to successful outcomes
- Change management experience and ability to drive success in a fast-paced, growing organization
- Demonstrated knowledge of CMS regulations, healthcare UM landscape, payor and provider organizations
- Highly skilled in leading significant change efforts and in building strong partnerships with business-line executives
- Ability to summarize complex issues and problems into concise reports focused on key findings and outcomes
- Passion for educating, teaching, and partnering up and down the organization
- Experience in utilization management, utilization review, and case management
- Experience with process improvement and business process documentation
- Demonstrated ability to research regulatory requirements for the clinical sector
- Demonstrated sophisticated written and verbal presentation abilities; substantial experience with the development of presentation materials (collateral, proposals, presentations, talking points, etc.)
- Computer and clinical, care management, EMR, software proficiency