AVP, Medical Management

US-CA-Los Angeles | US-CA-Santa Ana
Job ID
2017-5229
Category
Managed Care

Overview

This is a regional position that supports the Corporate Vice President of Medical Management in operational matters and has a dotted line reporting structure to the Regional Medical Director for clinical decision making as applicable to managed care and patient care coordination efforts.

 

The AVP is responsible for the execution of a strategic vision and implementation system-wide for a cross continuum care coordination management system, including case management, utilization review, patient admission necessity, discharge planning, readmissions, and transition management. The AVP works in tandem with the Regional Medical Director in the analysis of medical necessity opportunities, and the assessment of health care strategies for effective utilization of care coordination services for AltaMed members. The AVP implements standardized tools, roles and systems that are in alignment with AltaMed Corporate Medical Management Systems for the Orange County Region.

Responsibilities

  1. Provide strategic oversight of the management of medical utilization and case management activities including Medical, Behavioral Health, and Disease Management Programs
  2. Review activities, costs, operations and forecast data to monitor progress toward the Health Plan goals and objectives guiding the delivery of nursing care and ensuring consistent nursing standards
  3. Lead the administration’s actions that ensure compliance with National Committee on Quality Assurance (NCQA) and/or Joint Commission on Accreditation of Healthcare Organization (TJC) standards as determined for accreditation of the health plan
  4. Acts as a peer/partner to Line of Business (LOB) leaders, Managed Care Partners with Medical Director of Managed Care and/or Medical Director IPA to achieve desired outcomes
  5. Oversee internal and state Quality Management (QM) scorecard reporting, including analyzing validity of Clinical Quality management data/reports from a clinical perspective
  6. Provide oversight for Health Employer Data Information Sets (HEDIS) reporting and provides leadership to the development and realization of action plans to achieve targeted improvement goals
  7. Provide leadership for QM representation in new business activities (RFP responses, new market/product development, state contract changes etc.)
  8. Provide leadership to ensure compliance with the National Committee for Quality Assurance (NCQA) standards, or other accrediting bodies
  9. Ensure an effective process for reporting information to support provider re-credentialing, medical record reviews, and other performance and quality of care indicators
  10. Develop and manage annual operating and capital budget to sufficiently meet departmental needs and ensure the best utilization of resources
  11. Promote innovation to improve efficiencies within the organization; encouraging changes for the benefit of the health plan(s)
  12. Perform all other related duties as assigned

Qualifications

  1. Bachelor’s degree in Nursing or health Services required. Masters degree in health services or business administration or management preferred
  2. Current valid license as a registered nurse through the California Board of Registered Nursing required
  3. Minimum of 10 years experience in the acute care setting and/or medical group/IPA, Health Plan, Managed Care setting coupled with a minimum of 4 years of clinical care management, case management, utilization management or other related clinical management experience also required
  4. Knowledge of clinical care practices, operations and local, state and federal regulatory standards
  5. Must maintain current CPR/First Aid Training certification

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