Executive
Positions with Managed Care Organizations
Please
Contact:
Executive Search & Placement
Sonia Varian - 818-707-7118, or
espsonia@pacbell.net
CEO - HEALTH
PLAN - TEXAS WILL RELOCATE
Provides oversight for all Health Plan operations including: Provider
Contracting, Provider Services, Member Services, Marketing/Outreach, Finance,
Operations, Compliance, Human Resources, Legal, Legislative and Regulatory
Affairs. Additionally, represents the Health Plan at external venues within the
State implementing programs that are in alignment with strategic plan; providing
day-to-day leadership and management of the health plan that mirrors the
company's mission, vision, and core values; and ensure fiscal well-being of the
health plan. The Chief Executive Officer is responsible for designated state
health plans for the overall direction and administration of programs and
services provided by the health plan.
Principle Accountabilities
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Formulate and
implement business plans and strategies to provide for the profitable
operations, to meet short-term objectives and ensure long term growth and
success.
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Direct the
growth of the state plan, including overseeing business development
activities. Identify, analyze and recommend strategic alliances and/or
acquisitions to provide better products and services to members.
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Develop and
implement adequate measures to meet the fiscal needs of the company, to
conserve its assets and to maintain an effective system of budgetary
control.
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Review
forecasts and proposed capital expenditures. Recommend programs and policies
by analyzing the changing needs of the membership and industry; identify and
analyze trends and evaluate options.
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Amend existing
policies to improve operations and create new policies as needed. Present
reports and recommendations on the operations and finances of the state plan
and propose changes to major policies.
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Ensure the
overall level of quality for delivery of medical services meet or exceed
appropriate standards.
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Ensure programs
are established to comply with all relevant federal, state and local
regulations.
Required Skills
& Qualifications
Education: Bachelors’ and/or Masters’ degree in Business, Health Services
Administration or related field.
Experience: 10-plus year’s progressive healthcare experience in managed care
industry; 5+ years of management experience.
Strong working knowledge of Medicaid and Medicare products. Proven business
development and implementation managed care experience. Good working knowledge
of NCQA standards. Transition and/or acquisition experience is preferred.
DIRECTOR OF QUALITY IMPROVEMENT - SO. CALIFORNIA
The Quality Management Director is responsible for leading the developing the
staff within the Credentialing Department, Quality Management, Utilization
Management, Care Management, Disease Management and Health and Wellness
functions as a Medical Organization. The Quality Management Director will also
work closely with other departments in developing the Quality Management and
Disease Management programs and refining the programs as member and company
needs change.
Essential Duties and Responsibilities include the following.
As a member of the Senior Management Team, this position is responsible for the
oversight of Performance Improvement, Quality Management, Patient Safety/Risk
Management, Infection Control and Medical Staff functions.
This position is responsible for the oversight of Performance Improvement
Program and supports the use of evidence-based medicine to improve patient
outcomes and to optimize the use of resources.
This position works directly with the chairperson of the various medical staff
committees, Medical Directors and QM/UM Committee and Credentialing Committee to
facilitate Medical Staff Peer Review Activities.
Communicates with the Chief Executive to keep leadership current and informed on
all issues.
Maintains external and internal survey review readiness at all times; shows
evidence of compliance with all standards; keeps Lakeside managers and staff
fully informed of requirements and assists in developing plans to achieve such.
Collaborates regularly with functions across the health plan to ensure
coordinated delivery of care and services; integrates best practices across all
programs and product lines.
Supports all activities related to maintenance of NCQA Excellent accreditation
Education and/or Experience
At least 10 years of progressively responsible healthcare administrative
experience, with emphasis on Quality Management initiatives.
Licensed California nurse, preferably Registered Nurse
Bachelor's degree (B. A.) in Nursing, Health Sciences or Business; or five to
seven years’ related experience and/or training; or equivalent combination of
education and experience.
MEDICAL DIRECTOR
- HEALTH PLAN - FL (NON PROFIT ORGANIZATION)
Medical Director is responsible for the appropriateness and quality of medical
care delivered to members. The Medical Director shall develop processes for
medical reviews for coverage determinations for medical services and participate
in the grievance and appeals process. The Medical Director shall provide
guidance to health plan quality improvement, utilization management, as well as
continuous measuring, monitoring and improvement of the health delivery system
for plan members.
The Medical Director shall co-chair the Florida Quality Management Committee and
be a clinical member of all committees that report into the Managed Care
Executive Committee and all other committees that report Board of Directors.
Professionally represent Florida managed care in internal and external
correspondence including governmental representatives, healthcare providers,
community leaders and others. Provide clinical oversight and guidance to PHC/PHP
utilization review and care management programs as well as the Florida Disease
Management program by virtue of serving as co-chair of the Florida Quality
Management Committee. Examine information concerning patient outcomes, hospital
admissions, healthcare provider practice patterns and identification of clinical
outliers. Co-chair and provide clinical oversight and guidance to Florida
Quality Management Committee by assisting in quality management studies and
provider audits. Conducts population trend review and individual case reviews
for DM. Provides consultation to DM network providers on care management issues.
Coordinates and through collaborative processes in concert with the Quality
Management Manager produces at lease two Quality Improvement Projects (QIPs) and
two Performance Improvement Projects (PIPs) for the all managed care plans.
Medical Degree either MD or DO. Preferred Masters in Public Health (MPH) and/or
Masters in Business Administration (MBA) and/or Masters in Health Administration
(MHA). Board Certified in Primary Area of Medicine, Family Practice, Internal
Medicine, Pediatrics Minimum of 5 years clinical medical experience post
residency training. Minimum of 2 years experience in a managed care environment.
Will also consider Practicing Physicians interested in transitioning into
Managed Care Medical Director position.
DIRECTOR, PHARMACY CLINICAL SERVICES - HEALTH PLAN – CALIFORNIA
Reporting to VP of Pharmacy Services, this position will play a central role in
pharmacy management for a senior-focused Medicare Advantage Plan with over $140
million in annual drug expenditure. Director will be accountable for providing
leadership support to department, managing change, improving efficiencies and
managing and ensuring strong clinical programs aligned with organizational
direction. In addition, Director will service as Part D pharmacy expert for the
department and organization.
ESSENTIAL JOB RESULTS:
Serve as a clinical/subject matter expert on pharmacy benefit management
Coordinate the work product of clinical operation team members (clinical
pharmacists and pharmacy benefits administrators)
Oversee PBM operations to ensure high service level to the Health Plans and
members.
Oversee clinical and technical initiatives (eg. MTM, e-prescribing,
provider/member web based tools)
Monitor, evaluate, develop and implement quality initiatives (ie. DUR programs)
and drug cost management strategies
Serve to oversee clinical operations of pharmacy department to ensure proper
accuracy and efficiency.
Serve as backup of clinical operations when necessary (Grievances, appeals,
medication therapy management reviews, formulary management)
Participate in business and budget planning process.
Oversee pharmacy operations for Employer Group Retiree Plans
Lead department initiatives
Foster strong relations with internal departments and external providers
Serve as pharmacy expert on a variety of committees and workgroups
Maintain current knowledge of Medicare Part D regulations by participating in
CMS calls and reading released guidance.
PREFERRED QUALIFICATIONS: California State Board of Pharmacy, Registered
Pharmacy license required. Doctor of Pharmacy (Pharm. D.), with residency in
clinical pharmacy practice preferred. Five (5) years or more of managed care
pharmacy experience as a Director; or equivalent experience in a managed care
setting, strongly preferred. Demonstrated knowledge of Medicare Part D required.
Medicaid knowledge preferred. Excellent written, oral and interpersonal
communication skills required. Strong computer skills using MS Word, Excel and
PowerPoint required. Strong leadership, supervisory skills required. Strong
analytical, problem-solving, negotiation, and decision-making skills required.
Please Contact:
Executive Search & Placement
Sonia Varian - 818-707-7118, or
espsonia@pacbell.net
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