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Clinical Management Vice President (VP) in New York, NY at Beacon Health Options

Date Posted: 4/28/2019

Job Snapshot

Job Description

About the Position:

Beacon Health Options is currently seeking a dynamic Vice President of Clinical Management for our Clinical team in Manhattan, NY! The VP of Clinical Management is responsible for the direction and leadership of a performance driven utilization management program including on-going monitoring of operational performance and workforce management; the development, management and implementation of clinical programs and operations. Responsibilities also include regional provider strategy performance improvement; client issue resolution; management of medical loss ratio issues; and monitoring utilization data and trends in the assigned region.  This position will have oversight of the operational non-clinical and clinical teams ensuring all systems are in place to meet regulatory, client and clinical best practices.

Position Responsibilities:

Deliver effective and efficient clinical, quality, and provider strategy operations

  • Oversee regional CM programs, including complex case management, intensive case management, care coordination, and case consultation

  • Manage and monitor the Aftercare program including monitoring performance against internal as well as contractual (SLAs, PG) goals and collection of Non Standard Supplemental Data (NSSD)

  • In collaboration with internal and external stakeholders build sustainable integration programs and activities

  • Lead annual production of UM/CM/QM Regional Trilogy Documents, including monitoring work plan activity completion

  • Direct the implementation of the Regional Provider Quality and monitor outcomes

  • Direct and oversee regional clinical and service quality programs led by the Regional Quality lead

  • Develop Regional SOPs to support Corporate wide clinical, quality, and provider strategy policies when needed

  • Train/coach team members on corporate, market, and regulatory developments that impact their roles and functions

  • Ensure that team members are updated on changes in policies and procedures that impact their operations

  • Under the direction of Corporate Quality, ensure compliance with NCQA MBHO and URAC standards and contractual requirements

  • Ensure adequate participation in Corporate Quality Committees, specifically Corporate Quality Committee, Corporate Medical Management Committee, Corporate Utilization Management/Care Management Committee

  • Chair or assign designee for regional clinical, quality and provider Strategy team meetings

  • Oversee and Assign team members to implement new clinical programs, new client implementations assuring all deliverables for clinical, quality and provider partnerships are met

  • Work with the account team, the CMO and the growth officer in the region ensuring client clinical and quality requirements are met.

  • Monitor client clinical and quality CAPs and PGs for the region(OPS)

  • Collaborate with proposals and sales on new business development opportunities for supporting regional growth.

  • Represent Regional Clinical, Quality, and Provider Strategy on cross regional business development opportunities

  • Act as a liaison in URAC and NCQA accreditation and certification activities with Beacon’s Quality Team including: continuous monitoring for standard compliance, document retention and retention of certification and accreditation.

  • Responsible for ensuring that the operations of the regional UM team are aligned to support the regions MLR and clinical quality targets. Collaborate with Legal on compliance activities for UM operations to ensure we are maintaining all contractual, legal and accreditation requirements

  • Participate in customer meetings as needed and development and implementation of new business, including contract reviews, proposal requests, sales presentations, and RFP reviews

Responsible for monitoring performance improvement and program development activities

  • Work with the SVP of Clinical Management to identify necessary changes in UM algorithms to ensure appropriate authorizations are being automated; oversee algorithm adjustments and the operational processes to ensure their accuracy

  • Monitor, analyze, and report on trending of utilization data, working with the Regional Chief Operating Officer (RCOO), Regional Clinical and Quality Lead (RCQL), Regional Chief Financial Officer (RCFO) and SVP Clinical Management to recommend targets; to assess performance against established targets; and to facilitate effective interventions where variance from UM targets may be identified locally or regionally

  • Ensure that performance metrics across all clinical, quality, and provider quality are accurately and consistently monitored

  • Maintain a pro-active quality and process improvement program with in line with corporate policies, procedures and protocols, auditing mechanisms and data reporting systems

  • In collaboration with Corporate Quality and other regional center, proactively identify areas requiring performance improvement, and collaborate with stakeholders to develop improvement activities

  • Continuously monitor utilization management productivity and other operational metrics for region; identify issues related to changes in productivity; direct and oversee appropriate interventions to manage productivity to targets

  • Continuously monitor processes and procedures and develop recommendations to create efficiencies; direct and oversee recommended changes to processes and systems

  • Ensure successful completion of all internal and external accreditation, delegation, compliance, and legal audits

  • Oversee implementation of new clinical business, products, and specialty programs (e.g. Here For You)

Coordinate to solution client issues

  • Collaborate with UM functional area, Reporting and Analytics, and Finance for client contracts, including implementation and tracking of targeted intervention strategies and pricing/target feedback

  • Collaborate with Clinical Quality Standards lead on annual update of clinical policies and procedures, level of care criteria and selection of clinical practice guidelines

  • Collaborate with Ops Pod Leaders to develop effective and efficient processes to interface with Ops Pods to solution a range of client and other clinical, quality and operational issues

Oversee and Monitor Key Performance Indicators

  • Quantitative

    • Client satisfaction with clinical quality performance (e.g. HEDIS BH Measures, STARS)

    • Client satisfaction with Beacon’s collaboration and integration activities

    • Improved HEDIS BH Measure performance

    • Regional Member and Provider Satisfaction

    • Successful completion of client audits

    • Meeting and PGs/SLAs and monitoring/completing CAPs

  • Qualitative

    • Champion of executing against new clinical reporting structure

    • Champion of performance improvement and the CQI process

    • Effective partnering with UM Shared Services, Ops Pods, etc.

Employee Management/Development

  • Supervise and oversee Utilization Management Directors in the day-to-day operations of the UM department

  • Talent Development and Coaching

  • Management of Budgetary expectation

  • Oversight and delineation of staffing ratios and expectations

  • Provision of training

Position Requirements:

  • Education: Master’s Degree in a related field (healthcare administration, behavioral sciences, etc.) or RN with equivalent experience required

  • Licensure: Current, valid and unrestricted clinical licensure required with proof on date of hire with re-verification will take place no less than every 3 years.

  • Relevant Work Experience: 10 years managed behavioral healthcare or related experience, including experience with:

    • Leadership in utilization management practices and principles

    • Management of Medical loss Ratio

    • Clinical services

    • Quality management practices and principles

    • NCQA and/or URAC accreditation

    • HEDIS measures

    • Management information systems

  • Knowledge, Skills, & Abilities:

    • Knowledge and experience related to managed care clinical services and operations

    • Knowledge of regulatory and accreditation requirements necessary

    • Knowledge of NCQA and URAC standards and accreditation process

    • Knowledge of HEDIS BH measures

    • Knowledge of CQI tools and techniques

    • Ability to work cross-functionally, build consensus and develop staff/team performance

    • Ability to drive operational efficiencies while managing resulting impacts to MLR

    • Ability to identify opportunities for improvements and recommend and implement innovative solutions

    • Ability to work collaboratively with internal staff and external providers/clients

    • Ability to demonstrate strong customer service orientation with excellent written/verbal communication skill

    • Ability to work independently in an ever changing environment

    • Ability to prioritize multiple issues with excellent detail orient and organizational skills

    • Ability to track multiple projects/tasks, follow through as needed, and meet deadlines

To Apply:

Click below on “Apply for this Position” to create a profile and apply for the position

Beacon Health Options is proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment.  EOE/AA/M/F/Veterans/Disabled

At Beacon Health Options, our candidate's data privacy is a top priority. Our recruiting team conducts all communications using official company email (@BeaconHealthOptions.com). Only candidates who have applied for an open position through our Careers page (careers.beaconhealthoptions.com) will be engaged in our interview process. Beacon conducts all interviews in person or over the phone. At no time during the recruiting process will any Beacon recruiter request any financial or personally identifiable information from you.

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