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The Associate Vice President of Medical Management Operations is responsible for successfully executing all Medical Management activities for their region. The AVP is responsible for planning, organizing, and directing the administration of all Medical Management Programs such as Care Management (Utilization Management, Case Management, Disease Management), Advance Care Management (Palliative Care), and Quality programs. The VP provides oversight to ensure activities are appropriately integrated into strategic direction and operations, as well as the mission and values of the company.
The AVP maintains organizational structure and oversight of procedures, employment, training, and supervision of all Medical Management staff. The VP directs long-term planning and communication regarding Medical Management issues with network physicians; and acts as a resource to all internal and external customers. The Associate Vice President coordinates duties with appropriate personnel to meet operational program needs, ensures compliance with state and federal health plan requirements, Medicare guidelines, NCQA and URAC standards. The Associate Vice President implements policy and procedures to maintain corporate and service initiatives. The Associate Vice President integrates current clinical practice guidelines for care management services. The Associate Vice President is also responsible for cultivating new leadership for the department.
- Directs the overall activities of staff in the department. Serves as source of expert knowledge for all activities undertaken in the department. Establishes priorities for staff, and facilitates bilateral communication between line staff and department management. Serves as contact for communication and problem resolution for issues raised by managers from other departments. Presents professional appearance and demeanor at all times
- Actively participates in Medical Management and Quality Committee. Accountable for disseminating information to the Committee regarding market activities. This involves annual evaluation of the program with recommendations for revision as indicated. Actively participates in committees such as Medical Finance, market monthly strategic meetings, and other care management related committees
- Oversees and ensures that Care Management and Quality staff adhere to all regulations, contractual agreements, and applicable NCQA/URAC and other applicable accreditation standards. In addition, ensures adherence to other UM/CM/DM delegated agreement standards and expectations for all contracted health plans. Ensures internal audits are conducted, reviews results, formulates and implements appropriate action plans to correct any areas on noncompliance. Collaborates with Training to provide in-services on compliance to better prepare the department for audits. Makes recommendations for revisions and updates in structure and procedure to the enterprise VP and MM/Quality Committee for improvements to Medical Management functions and implements any new procedures
- Implements Medical Management programs in a manner that provides a high level of service to patients and providers, and is no more burdensome than necessary to manage the care effectively and efficiently
- Manages staffing ratios of all personnel, the assignment of duties, the supervision of the effectiveness of the Medical Management programs related to staff, within the structure of the budget for the department. Ensures staff have access to necessary training relevant to their duties to maximize operational efficiency using all resources available. Evaluates performance of staff on a timely basis, providing feedback in the most constructive manner. Implements Plan or Improvement for deficiencies in meeting Medical Management performance goals. Works with directors and managers to develop processes to meet the guidelines for employee ratio to work volume
- Encourages Medical Management staff to develop skills and knowledge for personal growth and promotion of position. Fosters leadership skills for supervisor positions to ensure most qualified staff performs management of processes. Promotes appropriateness in the utilization of staff by being flexible and assisting others when a staffing problem occurs. Identifies and helps develop future leadership candidates
- Maintains a personal level of professionalism through attendance at required meetings and evaluates problematic issues using all resources for resolution. Cultivates relationships with medical groups and primary care physicians as well as all departments within the enterprise for customer development and knowledge sharing. Keep abreast of all new or revised policies and procedures when posted or distributed and is accountable for distributing information to all committees. Conduct one on one session when indicated to promote staff development of knowledge and resource information
- Under the direction of the MM Committee, is responsible for maintaining a continuum in policy meeting national standards and health plan guidelines guaranteeing the effectiveness and success of the UM Program. Under the direction of Physician Advisory Committee, is responsible for development and management of clinical guidelines
- Promotes communication to customers by informing them of updates and revision in MM policies using training or orientation opportunities, newsletters, or other available resources such as forum presentations. Takes ownership of the total work process and provides constructive information to minimize problems and increase customer satisfaction
- Respects customer and organizational confidentiality. Also respects the confidentiality of contractual arrangements and personnel issues of Medical Management staff
- Resource Management: Designs and implements programs to eliminate inappropriate use of medical resources
- Uses all supplies and services in a resourceful and responsible manner
- Responsible for planning the Medical Management SG&A and capital budget and all expenditures within the framework of the company budget. This responsibility includes the management of salaries, operating expenses, and Medical Management assets used for daily operations
- Collaborates with Director of Delegation Management to ensure compliance with delegated requirements. Monitors monthly, quarterly and annual reporting according to delegation agreement and ensures annual assessments are conducted as applicable according to the delegation agreement, URAC, NCQA and CMS standards
- Reviews and analyzes all Management operational metrics, outcomes and utilization statistics. Identifies trends and patterns requiring intervention and process improvement. Responsible for implementation of UM, CM, DM and Quality work plans and annual program evaluations
- Performs all other related duties as assigned
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
- Ten or more years of management-level utilization management experience in managed care with health plans required, including five or more years of experience at the Director level or above
- Experience in contract language, claims, UM management guidelines and accreditation guidelines required
- Knowledge of federal and state laws and NCQA regulations relating to managed care, disease management, utilization management, discharge planning and complex care case management
- Knowledge of basic principles and practices of clinical nursing
- Knowledge of referral processes, claims, case management, and contracting and physician practices
- Knowledge of fiscal management and human resource management techniques
- Ability to effectively plan programs and evaluate accomplishments
- Ability to present facts/recommendations in oral and written form
- Ability to analyze facts and exercise sound judgment arriving at proper conclusions
- Ability to plan, supervise and review the work of professional and support staff
- Ability to apply policies and principles to solve everyday problems and deal with a variety of situations
- Ability to exercise initiative, problem-solving, decision-making
- Ability to establish and maintain effective working relationships with employees, managers, healthcare professionals, physicians and other members of senior administration and the general public
- Effective written and verbal communication skills
- Proficient with computer software programs, to include: word processing, spreadsheets graphics and databases
- Requires full range of body motion including handling and lifting patients as needed, manual and finger dexterity and hand-eye coordination
- Rarely must lift weight of up to 100 pounds
- Requires corrected vision and hearing to normal range, and must be able to speak clearly
- Requires working under stressful conditions or working irregular hours
- In and/or out-of-town travel is required
- Master's degree in Nursing or Business Administration preferred
- Fifteen or more years of experience in a managed care and/or disease/case/utilization management with ten or more years of management level experience
Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 380,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)
WellMed was founded in 1990 with a vision of being a physician-led company that could change the face of healthcare delivery for seniors. Through the WellMed Care Model, we specialize in helping our patients stay healthy by providing the care they need from doctors who care about them. We partner with multiple Medicare Advantage health plans in Texas and Florida and look forward to continuing growth.
OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare's support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.
Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Job Keywords: Optum, UHG, WellMed, Managed Care, Care Management, Care Operations, RN, Registered Nurse, Medical Management, Utilization Management, Case Management, Disease Management, Advance Care Management, Director, Sr. Director, Dallas, TX, Texas, managed care