Vice President, Health Services

The Vice President, Health Services is responsible for optimizing the quality and value of health care received by health plan members by providing consistent, innovative leadership and direction to design, implementation, analysis, monitoring and reporting of effective and efficient health management services across all lines of business. This includes management and oversight of all strategic and operational functions of the Case Management, Utilization Management, Quality Improvement, Behavioral Health, Pharmacy and Long Term Supports Services departments.  The position is also responsible for ensuring compliance with the state and federal requirements for these departments as well as related vendors. This position is also responsible for working in close collaboration with various Departments of Santa Clara County and Santa Clara Valley Health.

Responsibilities

1. Provides leadership, direction, and oversight to all of the Health Services areas (Case Management, Utilization Management, Quality Improvement, Behavioral Health, Pharmacy, Long Term Services and Supports, Process Improvement) and vendor(s) to ensure achievement of organizational, departmental and individual goals and maximize health outcomes for health plan members.
2. Designs, implements and administers best practices to ensure health care quality and value is maximized at the plan through appropriate utilization of health care services and contracts and relationships with delegates and vendors.
3. Assures effectiveness of departments by designing and monitoring key metric to continuously improve outcomes, and take targeted actions when metrics indicate improvement is warranted.
4. In conjunction with the Chief Medical Officer, develops and implements appropriate clinical policies and procedures and programs. Plans and prepares designated Committee meetings (Pharmacy and Therapeutics, Utilization Management, Quality Improvement). As well as assist with meeting.
5. Operationalizes new benefits, pilots and existing programs such as Palliative Care, Dual Eligible Special Needs Plan (DSNP), CalAIM, Student Behavioral Health Incentive Program (SBHIP) and Housing and Homeless Incentive Program (HHIP) among others.
6. Creates and reviews budgets of assigned departments as part of the annual planning and budgeting cycle and ongoing.
7. Contributes to the development of strategic planning for short and long term health plan goal development in conjunction with integration of Health equity measures to decrease disparities.
8. Develops innovative solutions to management and sharing of data needed for Health Services for operational and programmatic initiatives.
9. Drives new health services initiatives and collaborations across departments to support continuous improvement and health plan goals.
10. Instills a culture of Continuous Process Improvement, identify, design and implement Process Improvement opportunities, implement new systems required to support health services operations.
11. Supports and builds cross-functional relationships with key partners across the organization. Motivates teams and individuals to achieve goals, while enforcing accountability.
12. Ensures ongoing audit readiness and compliance with regulatory requirements from Centers for Medicare and Medicaid Services (CMS), CA Department of Health Care Services (DHCS), CA Department of Managed Health Care (DMHC) and National Committee for Quality Assurance (NCQA).
13. Develops and maintains positive collaborative relationships with providers, delegates, community-based groups (CBO), Santa Clara County Departments to enhance plan community presence and build mutual partnerships.
14. Manages, coaches, and trains staff including hiring, firing, and performance evaluation.
15.  Attend off-site meetings or events as necessary.
16. Perform other related duties as required or assigned.

Qualifications

1. Clinician with active unrestricted license to practice in the State of California (RN, NP, PA, LCSW, or equivalent clinical licensure).
2. Master’s degree in business, health care, public health, or related field.
3. Minimum of ten years of experience in senior-level management or director-level positions demonstrating increased levels of accountability.
4. Minimum of ten years of experience in mid to senior-level management positions demonstrating increased levels of accountability.
5. Demonstrated knowledge of CMS, DHCS and DMHC regulations.
6. Demonstrated knowledge of NCQA requirements and implementation.
7. Demonstrated successful leadership in program implementation and management and change management. Ability to plan, organize, administer and coordinate a variety of large and complex services, projects and programs.
8. Proven ability to exercise sound business judgment in determining priorities and resolving problems. Proven track record of success in plan management. Experience in strategic planning and development.
9. Successful leadership and management experience building effective teams, managing cross-functional teams and continuous improvement programs.
10. Ability to gather and analyze data, organize and write reports, and organize work efficiently.