RN Vice President of Medical Management - Managed Care
Baton Rouge, LA
The Vice President of Medical Management is responsible for the oversight, management and optimization of all Complex Case Management, Concurrent Review & Utilization Management, and Quality Management activities as they relate to healthcare delivery programs. Participates in the development, implementation and maintenance of all programs to ensure that patient care maximizes quality and continuity by utilization of appropriate resources and alternatives to inpatient care within the parameters of health plan benefits and established contracts. Ensures consistency and standardization of the application of these healthcare delivery programs across the regions, and the integration of these programs within the payment model. Works closely with all members of the team as well as Health Enhancement, Quality Improvement, Contracting and the Office of the Medical Director.
The VP will serves as a role model for all members of the company, by demonstrating the behavior and communication skills that exemplify the organizations commitment to superior customer service, including quality, care and concern with each and every internal and external customer. Ensures compliance with federal, state, and accreditation standards by developing, implementing and maintaining compliance processes within the department. Maintains audit readiness, by ongoing training, competency assessment, audit, monitoring of metrics and corrective action. Promotes plan-wide understanding, communication, and coordination of QM programs. Responsible for ensuring compliance and providing direction and guidance on clinical quality improvement and management programs including National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC), or general accreditation. Responsible for the reporting and analyzing of member care quality and for the development of plans and programs to support continuous quality improvement using HEDIS, CHAPS, and other tools. Ensures necessary steps are taken to achieve a successful year over year improvement of HEDIS measures. Identifies need for and participates in the development and implementation of care management and utilization management policies and procedures, and ensures compliance throughout the region and consistency throughout the network. Monitors closely and analyzes all inpatient and outpatient reports and identifies trends. Makes recommendations to the Regional Team regarding interventions to improve all resource management. Develops and coordinates strategies for ensuring the delivery of care in the most appropriate setting. Ensures that contracted providers are used and collaborates with contracting department to obtain new contracts with preferred providers based upon specific quality and utilization criteria. Monitors of all high-risk and high-cost patients in regard to care delivery, referrals, contracting, etc. Oversees cross-regional high-cost areas of Care Management (i.e., transplant or high-volume complex lines of business such as IPA or medical groups). Monitors provider referral patterns for appropriate utilization of specialty and ancillary services. Initiates organizational and system changes to improve departmental staffing efficiency and effectiveness, and care management program outcomes within the region. Coordinates or performs projects/activities as delegated by organizational committees and Supervisor. Participates and supports organizational committees as appropriate, per regulatory guidelines. Identifies, develops and oversees the educational needs of the Care Management providers and staff including the implementation of an extensive orientation program, cross-training and proactive approach to Care management. Identifies opportunities for the development of new care management approaches and prepares proposals with cost analysis, Information System requirements, educational needs and implementation plan to be presented to the centralized team for network-wide implementation. Motivates and leads the Medical Management staff in setting and reaching goals for continuous improvement in quality, service and cost-effective care to all members.
Valid, unrestricted state Registered Nurse (R.N.) license
Requires a Bachelors’ Degree in Nursing, Public Health, Administration, or related field; Master's Degree preferred
Certified Professional in Utilization Management/Review (CPUM/CPUR) or Certified Professionals in Healthcare Quality (CPHQ).
5-7 years’ clinical nursing or social work experience; preferably in an acute care hospital setting required .
3- 5 years previous management experience, in roles of increasing responsibility.
At least 5 years’ experience with medical management (CM/UM/QM) at a Managed Care Organization, such as Health Plan, IPA, Medical Group, or HMO.
Requires direct experience in successfully achieving National Committee for Quality Assurance (NCQA) accreditation.
Experience with strategic planning, implementing, and evaluating clinical programs.
Knowledge of utilization management, quality improvement, discharge planning, and cost management.
Possess planning, organizing, conflict resolution, negotiating and interpersonal skills.
Excellent verbal and written communication skills, as well as exceptional critical thinking skills.
Possess very strong coaching/counseling skills including the ability to function as a mentor to management and employees.
Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.
EXCELLENT BENEFITS AND HIGHLY COMPETITIVE SALARY OFFERED!
This established, nationally-recognized organization is a Fortune 500 company that is committed to the health and happiness of all their staff. They offer a comprehensive benefits package to all full-time, permanent employees including low cost health insurance plan, dental, vision, and life insurance. To assist employees in living a healthier life, they offer either on-site fitness center or discounts to local fitness centers and a comprehensive wellness programs. They also offer free or reimbursed parking, tuition assistance, matching 401(k), employee stock purchase plan, generous PTO plus paid holidays, and much more!