City/State

Tallahassee, FL

Overview

Work Shift

First (Days) (United States of America)

Sentara Health Plans is recruiting a Vice President, Medicaid Case Management and Utilization Management in Florida! Sentara Care Alliance, a service of Sentara Health Plans, is the visionary leader responsible for the long-term success and sustainable growth of our Florida-based organization providing vital health coverage to Florida's Medicaid beneficiaries.

Provide Leadership and Transformation of Medicaid UM/CM Programs. Continuous improvement in Medicaid clinical performance including readmissions, chronic care utilization and unplanned care through CM outreach and programs. Adherence to each state's Medicaid contract UM/CM requirements. Coordination with Medicare UM/CM to ensure seamless care and management of DSNP aligned members. Collaboration and Partnership with ICMs, SMG and SQCN/SACO to create a differentiated experience for shared patients. Support Medicaid growth through RFP responses, new plan builds and new program creation.

-Drive performance in outcomes and build new programs in Population Health and Disease Management
-Work with CM teams to identify and address opportunities in sub-populations for program development
-Identify opportunities for linkage and coordination between Ambulatory, Hospital and CIN divisions across the care continuum
-Partner with VBC Leadership to support provider performance in new payment models
-Support programs designed to improve performance on HEDIS, STARs and efficiency measures
-Create linkages with, quality, pharmacy, palliative care, and community impact in the development of programs
-Identify opportunities for improvement in outcomes, cost of care and member experience; Identify opportunities for enhanced collaboration across the care continuum and the creation of a differentiated experience for shared patients
-Develop and implement training programs for clinical teams
-Ensure adherence to regulatory, compliance and accreditation rules and directives

8-10 years Progressive Leadership Experience in UM/CM leadership in a health plan with proven outcomes in utilization management, member engagement, chronic disease management and reductions in unplanned care
Experience in matrixed leadership structure
Demonstrated ability to build cross-functional programs...
5 years Direct Health Plan UM/CM experience in Medicaid

#LI-AR1

Job Summary

Leadership and Transformation of Medicaid UM/CM Programs in support of One Sentara. Continuous improvement in Medicaid clinical performance including readmissions, chronic care utilization and unplanned care through CM outreach and programs. Adherence to each state's Medicaid contract UM/CM requirements. Coordination with Medicare UM/CM to ensure seamless care and management of DSNP aligned members. Collaboration and Partnership with ICMs, SMG and SQCN/SACO to create a differentiated experience for shared patients. Support Medicaid growth through RFP responses, new plan builds and new program creation.
-Drive performance in outcomes and build new programs in Population Health and Disease Management
-Work with CM teams to identify and address opportunities in sub-populations for program development
-Identify opportunities for linkage and coordination between Ambulatory, Hospital and CIN divisions across the care continuum
-Partner with VBC Leadership to support provider performance in new payment models
-Support programs designed to improve performance on HEDIS, STARs and efficiency measures
-Create linkages with, quality, pharmacy, palliative care, and community impact in the development of programs
-Identify opportunities for improvement in outcomes, cost of care and member experience; Identify opportunities for enhanced collaboration across the care continuum and the creation of a differentiated experience for shared patients
-Develop and implement training programs for clinical teams
-Ensure adherence to regulatory, compliance and accreditation rules and directives
8-10 years Progressive Leadership Experience in UM/CM leadership in a health plan with proven outcomes in utilization management, member engagement, chronic disease management and reductions in unplanned care
Experience in matrixed leadership structure
Demonstrated ability to build cross-functional programs...
5 years Direct Health Plan UM/CM experience in Medicaid

Qualifications:

MD - Doctor of Medicine, MLD - Master's Level Degree: Business Administration/Management, MLD - Master's Level Degree: Health AdministrationCase Managment - Certification - Other/National, Medical Doctor (MD) - Certification - Other/National, Registered Nurse License (RN) - Nursing License - Compact/Multi-State License, Utilization Management - Certification - Other/NationalCase Management Leadership, Direct Health Plan UM/CM experience in Medicaid, Leadership, Matrixed Leadership Structure

Skills

Sentara Healthcare prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

Per Clinical Laboratory Improvement Amendments (CLIA), some clinical environments require proof of education; these regulations are posted at ecfr.gov for further information. In an effort to expedite this verification requirement, we encourage you to upload your diploma or transcript at time of application.

In support of our mission "to improve health every day," this is a tobacco-free environment.