The VP of Health Plan Operations is a leadership position within the medical management group that serves under the direction of the SVP, Health Plan Operations. This person serves as the primary interface with internal medical management executive staff, organization wide-governing committees, contracted health plan representatives and other various health care vendors. The VP provides oversight for development of strategies and processes, direction of staff, and execution of operational tasks within the scope of the operations unit. Key areas of responsibility include health plan audits, management of corrective action plans, internal audits, policies and procedures,, continuity of care, letters of agreements, contracting, provider liaison.
We are seeking health plan executives who are career-driven, have a track record of relationship building among key opinion leaders. We are looking for candidates with a depth of experience in utilization management and case management experience. We offer accelerated career growth potential, and excellent benefits. We have many opportunities and consider only the best healthcare executives to join our health plan leadership teams.
typical roles and responsibilities for VP Health Plan Operations
Maintains audit readiness, by ongoing training, competency assessment, audit, monitoring of metrics and corrective action.
Promote organization-wide understanding, communication, and coordination of UM/CM programs.
Participate in organization-wide Quality Management Program through the collection, aggregation and reporting of utilization management / care management and quality monitoring activities to the quality committee.
Implement processes to coordinate and report continuity of care activities are performed timely and in compliance with regulatory mandates.
Implement auditing methodologies that support effective internal project monitoring to promote ownership and alignment with department objectives.
Provide oversight of utilization management/care management health plan related delegated function reporting activities.
Provide oversight of operations to support health plan contractual business and management services agreement functions
Ensure the preparation and distribution of utilization and quality management reports for assigned committees indicating utilization and quality management patterns.
Resolve issues by identifying the problem, examining solution options, implementing an action plan and providing resources.
Oversees program and policy and procedure development to ensures compliance with current industry regulations
Plan and direct the development and delivery of training and educational programs for all department personnel.
Requirements for VP of Health Plan Operations
Bachelor’s degree and Master’s Degree in a health affiliated or business affiliated field or Registered Nurse (R.N.) license with a Bachelor’s Degree
10+ years of relevant professional experience required and knowledge of medical management clinical review criteria, processes, and techniques.
7+ years of managerial experience,
5+ years of managed care experience, including Medicaid, Medicare and commercial insurance payer systems that includes health plan level.
Project management experience in planning, implementing, and controlling of medical projects.
Working knowledge of various accreditation standards, such as NCQA or URAC, etc.
Strong working familiarity with claims payment rules and their impact on care management processes.
Knowledge of healthcare and managed care industry current and future trends, in order to assess future market needs
Strong computer proficiency (MS Office)
Experienced in performing utilization management oversight activities
Comprehensive knowledge of managed care industry standards and familiarity with government regulations
A depth of experience in interpreting full-service health plan contractual DOFR and delegation logic requirements, in-depth understanding of regulatory and accreditation compliance, and experience in medical management program development.