The Director of Health Services is responsible for the strategic implementation, program development, and oversight of clinical operations for the CCC Plus and Dual Special Needs Programs in collaboration with the Associate Vice President of Health Services. The Director coordinates duties with appropriate personnel to meet operational program needs, ensures compliance with state and federal health plan requirements, makes recommendations for program enhancements to improve care delivery, ensures compliance with NCQA guidelines, and provides leadership presence in the satellite offices throughout the state. . The Director will assist senior leadership with long-term planning initiatives to maintain operations assuring activities are appropriately integrated into the overall strategic plan for the organization.
Responsible for planning and implementing assigned regional market success initiatives with each region’s team
Oversees the Health Services’ Department and staff role s and responsibilities
Works with medical management staff to provide guidance and/or intervention in problematic/unusual cases in all office locations
Supports company-wide initiatives within the VCU enterprise and with external entities
Serves in an advisory capacity for problem solving, reviewing reports being sent to internal and external customers, reviewing problematic cases, and monitor case management activities
Participates in public speaking presentations and community education initiatives on behalf of Virginia Premier as needed
Assists AVP of Health Services in ongoing Quality Improvement initiatives by assisting with various quality review tasks such as collecting and analyzing data as outlined in the program
Ensures program processes and policies are aligned with NCQA standards
Assists in the ongoing development of programs and medical management projects to enhance/expand the case management/care coordination program
Ensures business processes are in place to monitor and manage the CCC Plus and DSNP operational processes as defined by the state contract and/or national standardized model components
Monitors and tracks program metrics, dashboards, and other reporting tools to drive action and improvements
Analyzes data to identify under/over utilization; improve resource consumption; promote potential reduction in cost; and enhance quality of care consistent with health plan’s strategic goals and objectives
Drives program deployment: understands strategies and issues, drives plans, ensures smooth transitions
Define, document and prioritize change impacts for clinical programs across functions
Provides training, mentoring and coaching where appropriate
Participates in audit activities as required in the state contract and for NCQA accreditation
MINIMUM EDUCATION REQUIREMENTS
Minimum education degree of Bachelors of Science in a health care field
License – Current Registered Nurse licensed to practice nursing in Virginia;
Certified Case Manager (CCM) preferred
SPECIAL KNOWLEDGE AND/OR SKILLS
Highly motivated individual with the ability to work independently as well as part of a team
Excellent verbal and written communication skills
Knowledge of NCQA and HEDIS
Demonstrated knowledge of Case Management principles
Strong analytical problem-solving, time management, and organizational skills
Proficient Microsoft Office product computer skills
Knowledge of community resources and vendor options and experience in making appropriate referrals
Ability to negotiate with providers, vendors and care providers
Knowledgeable in process improvement methodology such as LEAN and Six Sigma
Knowledge in program start-up and/or enhancements
Minimum of 5 years of case management experience preferably in a managed care setting
Minimum of 5 years of management experience
Knowledge of utilization management, preferably service authorizations related to waiver services
Minimum of 2 years of experience in Medicaid and Medicare managed care
Physical health sufficient to meet the ergonomic standards and demands of the position.
All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE
Our mission is to inspire healthy living within the communities we serve!
Virginia Premier is a managed care organization owned by the Virginia Commonwealth University Medical Center. We inspire healthy living within the communities served by VCU Health System, in Virginia and beyond, through innovation, strategic partnerships, and industry-leading healthcare, with a focus on underserved and vulnerable populations.
We are committed to recruiting, employing and retaining individuals who will live our philosophy of providing the best service to our members, providers, vendors and internal customers.
With locations all across the state of Virginia, we are proud of our track record of developing and promoting our employees. We encourage our employees to take advantage of our multiple ways to continue their education, including our generous Tuition Reimbursement Program. We are committed to the continuous growth and development of our most valuable asset, our employees.