Vice President Clinical Programs Medicaid - JHP

Job Details

Job Description

The incumbent works in conjunction with the VP and Chief Clinical Officer (CCO) and is charged with oversight of Clinical Operations and case management / care coordination for Medicaid and CHIP lines of business. Additionally, the incumbent oversees the areas of relevant PA state reporting, that includes Department of Human Services (DHS), PA Insurance Department (PID), and Department of Health (DOH), as it relates to Special Needs, EPSDT requirements and case management. The incumbent is responsible for the oversight of applicable Accreditation Standards.

Essential Functions:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Able to work in a constant state of alertness and safe manner
• Oversee and expand the clinical care management programs to support member specific needs to improve health outcomes, in addition to meeting regulatory and accreditation requirements for Medicaid and CHIP lines of business.
• Develop a strategy of coordinating the collection of relevant data that demonstrates improvement of health outcomes and correlates to the case management clinical programs
• Lead organizational efforts to implement relevant and timely Clinical and Regulatory - based programs with executive leadership sponsorship and collaborative teams that are cross-departmental
• Participate in the organizational effort to achieve full NCQA accreditation status and distinction in CLAS for all relevant areas of oversight for clinical programs
• Develop processes to ensure documentation and compliance with all regulatory and accreditation requirements and responsibilities for all areas of oversight
• Participate in the Quality Management Committee structure and coordination.
• Oversee and monitor clinical programs and relevant work plans and ensure timely completion of work plan activities and documentation at appropriate committees.
• Assure development and review of policies and procedures for all relevant business units.
• Ensure compliance with operational regulatory and accreditation reporting requirements as relevant to areas of oversight
• Assure representation of division on subcommittees such as Delegation Oversight, Clinical Quality Committee, Service Quality Committee and UM/P&T.
• Coordinate and oversee the Plans Provider Pay for Performance initiatives
• Participate in the Plans Member Incentive programs
• Coordinate department's activities in conjunction with the Health Partners Plans Pay for Performance Program
• Write Business Requirements for relevant reporting and analytical dashboards to support programmatic monitoring and improvements.
• Collaborate with all relevant departments, divisions and peers to ensure successful implementation of and monitoring for all clinically relevant programs
• Provide timely and relevant updates to the CP and Chief Clinical Officer on all clinical programs activities, including opportunities, analysis of effectiveness of programs and recommendations for change as indicated.
• Work with directors and management to develop process improvement activities in alignment with findings on ongoing auditing to ensure regulatory and accreditation requirements as well as internal thresholds for performance.
• Oversee and develop staff to seek and secure opportunities for the Plan in the clinical and quality arenas based on current trends and best practices.
• Recruit, attract, develop, motivate and retain a high caliber of business managers and professionals.
• Maintain a positive work environment that supports self-direction; provide a structure to optimize experience, skill, knowledge and capability of the team.
• Reward business managers and professionals based on contribution and performance.
• Oversee and manage budget and control expenses while meeting operational, financial and service requirements.
• Monitor divisional human resource issues, including productivity, key performance indicators, compliance with Human Resource policies and support of directors and managers.
• Provide necessary support and guidance to divisional management team.
• Monitor divisional progress against corporate goals and objectives.
• Perform other duties as assigned

Education:

• RN Degree (Required) and licensed in Pennsylvania with
• 7-10 years' experience in managed care and/or indemnity insurance with a minimum preferred
• Minimum of 7 years in a management position preferred
• Advanced degrees in relevant field or Certification in Healthcare Quality and/ or Case Management preferred

Skills/Abilities:

• Strong interpersonal skills, oral and written communication skills and analytical ability required
• Working knowledge of accreditation standards required
• Performance improvement methodology and best practices required

• Knowledge in developing and managing budgets required
• Conflict resolution and independent decision-making skills required
• Expertise in computer software, including Microsoft Office and Database applications, especially in Excel and Access required.
• Experience in managing cross-functional teams required
• Demonstrated success in planning and implementation required
• Strong influencing, negotiation and analytical skills required

Work Shift

Worker Sub Type

Primary Location Address

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.