Role details

Vice President, Clinical Operations

New York   •  Permanent

Bullet points

  • MLTC expereince required
  • Oversse medical management, utilization management, and UAS assessments

About Our Client

Our client is the largest not-for-profit home health care agency in the United States, and they are one of the oldest. They have been part of the fabric of New York City since the 1800s. Our client has recently dedicated new resources to their MLTC product line and is seeking top talent to help grow and maintain their health insurance business.

Job Description

  • Collaborates with leadership on the development of health plan strategies, initiatives, services and guidelines across the continuum of managed care product lines.
  • Proposes programmatic changes and innovative strategies to improve healthcare quality and outcomes based on assessment of current practices and professional clinical/operational skills. Recommends plans for implementation of new/revised programs.
  • Develops and oversees HIT (health information technology) Systems that support the coordination of services and analysis of utilization.
  • Guides management team in selection of performance indicators/outcome measures.
  • Oversees Assessment unit and external delegated vendor partners to ensure timely assessments of each member's medical, behavioral health, long-term services and supports, and social needs. Ensures the assessments are provided within the standards of nursing practice and in accordance with established guidelines and DOH/CMS regulations.
  • Provides leadership and direction to the Care Coordination management team. Ensures that high quality, culturally sensitive and cost effective services and benefits are provided to members by staff and/or contracted vendors.
  • Monitors departmental compliance to changing regulatory requirements at Federal and State level and insure that all indicators meet or exceed requirements. Updates leadership and management on pertinent clinical services issues and/or federal, state regulatory changes impacting care management and utilization processes.
  • Prepares presentations for committee/Board of Directors.
  • Ensures that all subcommittee chairs are held to the charter vision and accountable to the Plan Quality Improvement Committee.
  • Develops Utilization Management/Care Management program in expansion counties and staff that conform to State and Federal Regulations.
  • Represents the Plan's Medicare/Medicaid UM/CM at professional meetings.
  • Coordinates and develops Models of Care incorporating "Care Coordination".
  • Assists in State and Federal Readiness Reviews/Compliance Audits for new products (i.e. FIDA).
  • Keeps up to date on the latest issues and trends relating to Health Plans and advances in the industry through networking, professional memberships, and select journal reading. Synthesizes trends and determines application and integration into department.
  • Performs all duties inherent in a senior managerial role. Approves staff training, hiring, promotions, salary actions and terminations. Prepares and ensures adherence to department budget. Recommends and monitors productivity and staffing ratios to achieve administrative cost ratio targets.
  • Participates in special projects and performs other job duties as required.

The Successful Applicant

Education: Bachelor's Degree in Business or a related discipline or the equivalent work experience required.

Experience: Minimum ten years Utilization Management experience in a managed care/HMO organization required. Minimum five years managerial experience required. Experience with State and external accreditation managed care audits and reviews required. Experience with writing and implementing program level policy and procedures required. Proficient with computer and software programs (e.g.; Microsoft Word, Excel) and the Internet required. Experience applying medical management treatment guidelines, such as InterQual / McKesson, Milliman, or other practical management guidelines required.

What's on Offer

Commensurate with experience.

Apply for this job

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