Health Plan Executive Position

Location

Note

Business Development: Evaluates opportunities/need for new programs and/or service lines.
Evaluates program/service line based on service areas, payor mix, target segments and potential market share.
Develops Operational Business Development Plans with input from and collaboration with CFO, other product line experts, Business Development Department and physician leaders.
Develops program/service line operational plans to include needed proforma, marketing strategies and implementation agenda

Marketing: Evaluates and formulates marketing plan for divisional area based on the hospital mission statement and strategic plan.
Develops and implements methods to attract and maintain current customers.

Leadership: Where identified, assumes management responsibility for directing/overseeing service lines for the continuum and/or multiple sites.
Develops a collaborative effort between the Patient Care Division and the entire healthcare organization and medical staff in the areas of problem solving, risk taking and resultant change.

Finance: Acts as a resource to management and supervisory staff on all aspects of the budgeting process to include projections of volume, revenue, salaries and supplies.

Requires a California State Registered Nurse License. Three years recent experience as a unit manager of equivalent management experience. Master Degree/or in process of degree is required. Strong knowledge base or experience in specialty areas assigned. Minimum 3 years Home Health Nursing experience with 3 years Home Health Leadership experience.
 

• Collaborates with disciplines in developing and maintaining Managed Care clinical programs.
• Works closely with managers to facilitate adherence to plan operational standards and regulations
• Responsible for Project Management related to clinical program, including UM, CM, QM and Grievance and Appeals.
• Assures timely reporting of required data through the Quality Management Committees and contracting private and/or governmental agencies, e.g., California DHS-MMCD, Medicare CMS, etc.
• Develops relationships with key internal and external providers in order to facilitate collaboration and growth of the managed care clinical programs.
• Demonstrates comprehensive knowledge of Department of Managed Health Care (DMHC) Knox-Keene Licensure regulations and operational requirements, California Department of Health Services (DHS) MediCal Managed Care regulations and operational requirements and Centers for Medicare and Medicaid Services (CMS) Medicare Advantage and Part D regulations and operational requirements.

Education and/or Experience
Registered Nurse, licensed in the State of California with a Bachelors degree in Nursing, Masters degree preferred or Registered Nurse with demonstrated comparable managerial and executive experience. Minimum five years experience in managed care (with an emphasis in Medicaid and Medicare managed care strongly preferred). Minimum 3 years experience in managed care administration.