Director, Health Services - SECUR Health Plan

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Job Summary

• **This is a hybrid role that requires 3-4 days in the corporate office/week**
  
  

Leads health service strategy for high- risk population to improve the health outcomes of Medicare beneficiaries by addressing their social and clinical needs.

Implements policy, procedures and protocols addressing clinical and quality care plans for enrollees.

Develops Health Services organization structure and care operations that include utilization management, care management, disease management, discharge planning and onsite current review.

Develop and implement strategic plans, goals, and objectives in alignment with the organization's vision and mission.

Coordinate and supervise the activities of health staff, while monitoring and evaluating the performance, quality, and outcomes of targeted health services and programs.

Manage the budget, finances, and contracts of the health department.

Establish and maintain partnerships with other internal business units and external delegates.

Identify and address the health needs of the population served by the organization while advocating for policies that promote health equity and social justice.

Responsible for ensuring compliance with all applicable internal, state and federal policies, processes, and procedures.

Develops and implements prior authorization, referral and other utilization management rules for the organization.

Oversees and participates in state, federal, and internal audits, as needed.

Manages staff responsible for clinical decision-making, care coordination, transitions of care, complex disease management programs, and concurrent reviews.

Ensures all health services department activities performed in accordance with the Centers for Medicare & Medicaid rules and regulations are completed timely, accurate and completely.

Serves as primary interface with stakeholders and business partners and ensures standard processes are implemented.

Oversees preparation of narratives, graphs, flowcharts, etc. to be used for committee presentations, audits and internal/external reports; oversees necessary correspondence in accordance with regulatory requirements.

Develop, create, and implement policies and procedures, workflows and job aides as required to provide training for the health services department.

Leads health service strategy for high- risk population to improve the health outcomes of Medicare beneficiaries by addressing their social and clinical needs.

Implements policy, procedures and protocols addressing clinical and quality care plans for enrollees.

Develops Health Services organization structure and care operations that include utilization management, care management, disease management, discharge planning and onsite current review.

Develop and implement strategic plans, goals, and objectives in alignment with the organization's vision and mission.

Coordinate and supervise the activities of health staff, while monitoring and evaluating the performance, quality, and outcomes of targeted health services and programs.

Manage the budget, finances, and contracts of the health department.

Establish and maintain partnerships with other internal business units and external delegates.

Identify and address the health needs of the population served by the organization while advocating for policies that promote health equity and social justice.

Responsible for ensuring compliance with all applicable internal, state and federal policies, processes, and procedures.

Develops and implements prior authorization, referral and other utilization management rules for the organization.

Oversees and participates in state, federal, and internal audits, as needed.

Manages staff responsible for clinical decision-making, care coordination, transitions of care, complex disease management programs, and concurrent reviews.

Ensures all health services department activities performed in accordance with the Centers for Medicare & Medicaid rules and regulations are completed timely, accurate and completely.

Serves as primary interface with stakeholders and business partners and ensures standard processes are implemented.

Oversees preparation of narratives, graphs, flowcharts, etc. to be used for committee presentations, audits and internal/external reports; oversees necessary correspondence in accordance with regulatory requirements.

Develop, create, and implement policies and procedures, workflows and job aides as required to provide training for the health services department.

Leads health service strategy for high- risk population to improve the health outcomes of Medicare beneficiaries by addressing their social and clinical needs.

Implements policy, procedures and protocols addressing clinical and quality care plans for enrollees.

Develops Health Services organization structure and care operations that include utilization management, care management, disease management, discharge planning and onsite current review.

Develop and implement strategic plans, goals, and objectives in alignment with the organization's vision and mission.

Coordinate and supervise the activities of health staff, while monitoring and evaluating the performance, quality, and outcomes of targeted health services and programs.

Manage the budget, finances, and contracts of the health department.

Establish and maintain partnerships with other internal business units and external delegates.

Identify and address the health needs of the population served by the organization while advocating for policies that promote health equity and social justice.

Responsible for ensuring compliance with all applicable internal, state and federal policies, processes, and procedures.

Develops and implements prior authorization, referral and other utilization management rules for the organization.

Oversees and participates in state, federal, and internal audits, as needed.

Manages staff responsible for clinical decision-making, care coordination, transitions of care, complex disease management programs, and concurrent reviews.

Ensures all health services department activities performed in accordance with the Centers for Medicare & Medicaid rules and regulations are completed timely, accurate and completely.

Serves as primary interface with stakeholders and business partners and ensures standard processes are implemented.

Oversees preparation of narratives, graphs, flowcharts, etc. to be used for committee presentations, audits and internal/external reports; oversees necessary correspondence in accordance with regulatory requirements.

Develop, create, and implement policies and procedures, workflows and job aides as required to provide training for the health services department.

• Lead strategy to document comprehensive assessments of comorbidities and all chronic conditions during all visits.
• Documents HEDIS and Star quality measures during practice, preventive assessment and personalize care plans.
• Develop and implement strategic plans, goals, and objectives in alignment with the organization's vision and mission.
• Coordinate and supervise the activities of health staff, while monitoring and evaluating the performance, quality, and outcomes of targeted health services and programs.
• Identify and address the health needs of the population served by the organization while advocating for policies that promote health equity and social justice.
• Develop, create, and implement policies and procedures, workflows and job aides as required to provide training for the health services department.
• Develops and implements prior authorization, referral and other utilization management rules for the organization.
• Manages staff responsible for clinical decision-making, care coordination, transitions of care, complex disease management programs, and concurrent reviews.
• Ensures all health services department activities performed in accordance with the Centers for Medicare & Medicaid rules and regulations are completed timely, accurate and completely.
  
  

Qualifications

• Bachelor’s Degree or equivalent combination of education and experience.
• Master’s Degree is preferred.
• Prior history of reporting directly to a Medical Director preferred.
• 4-6 years supervisory experience within a Health Plan or MSO setting for Medicare Advantage product lines. Special Need Plan and specific ISNP products are preferred.
• Familiar Model of Care (MOC) requirements and practices to ensuring proper documentation of the unique needs of enrollees through treatment and care plans.
• 5 years’ experience in Medicare Advantage utilization, discharge, planning and care management strategies and achieving high standards of clinical outcomes and metrics for quality of care.
• Familiar with High Needs ACOs and associated quality metrics preferred.
• Ability to clearly present written information and findings, concisely communicate concepts and make executive-level presentations.
• Prior experience providing provider level metric education.
• Strong and effective verbal and written communication skills to multi- level audiences.
• Demonstrates good judgment, organization and prioritization skills and time management skills.
• Proven leadership with staff, projects, and management.
• Strategic thinking abilities and analytical skills.
• Proficient with Microsoft Office applications, including Word, Excel, Outlook and various database applications.
• Detail oriented with problem-solving abilities.
• Exemplary interpersonal and customer service skills. Demonstrates professionalism, poise, tact, and diplomacy in interactions with others.
  
  

Competencies

• Satisfactorily complete competency requirements for this position.
  
  

Responsibilities Of All Employees

• Represent the Company professionally at all times through care delivered and/or services provided to all clients.
• Comply with all State, federal and local government regulations, maintaining a strong position against fraud and abuse.
• Comply with Company policies, procedures and standard practices.
• Observe the Company's health, safety and security practices.
• Maintain the confidentiality of patients, families, colleagues and other sensitive situations within the Company.
• Use resources in a fiscally responsible manner.
• Promote the Company through participation in community and professional organizations.
• Participate proactively in improving performance at the organizational, departmental and individual levels.
• Improve own professional knowledge and skill level.
• Advanced electronic media skills.
• Support Company research and educational activities.
• Share expertise with co-workers both formally and informally.
• Participate in Quality Assessment and Performance Improvement activities as appropriate for the position.
  
  

Leadership Success Factors

• Communication. Express thoughts and ideas clearly. Adapt communication style to fit audience.
• Initiative. Originate action to achieve goals.
• Management Identification. Identify with and accept the problems and responsibilities of management.
• Judgment. Make realistic decisions based on logical assumptions, factual information and in consideration of organizational resources.
• Planning, Organizing and Controlling. Establish course of action for self and/or others to accomplish a specific goal; plan proper assignments of personnel and appropriate allocation of resources. Monitor results.
• Leadership. Use appropriate interpersonal styles and methods in guiding others.
• Ethics. Model highest standards of conduct and ethical behavior, adopting a strong position against fraud and abuse.
• Regulatory Compliance: Educate and monitor staff regarding their own and the Organization's responsibilities for regulatory compliance.
  
  

This position requires consent to drug and/or alcohol testing after a conditional offer of employment is made, as well as on-going compliance with the Drug-Free Workplace Policy.