Executive Positions with Managed Care Organizations
Please Contact:
Executive Search & Placement
Sonia Varian - 818-707-7118, or
espsonia@pacbell.net
DIRECTOR OF QUALITY IMPROVEMENT -
HEALTH PLAN - MIDWEST
Responsible for the planning,
developing and directing of Quality Improvement functions.
Provide leadership, management and supervision of the Quality
Improvement Department operations and staff, to ensure that the
quality of healthcare services rendered meets or exceed
professionally recognized community standards. Develop and
implement measures and controls to achieve company's goals.
Duties and Responsibilities
* Lead the design,
development and implementation of the overall Quality
Improvement Program. Accountable for timely program revisions to
meet regulatory and accreditation agencies' requirements.
*
Analyze, update, and modify standard operating procedures and
processes to continually improve QI Department
services/operations. Assist in strategizing and facilitating
various committee structures and functions to best address the
QI process.
* Coordinate and complete of all QI activities
required to meet NCQA accreditation standards. Initiates and
coordinates the development of Practice Guidelines.
* Develop
and conduct Quality Improvement studies. Responsible for
oversight of HEDIS, Disease Management and Health Education
programs. Prepares analyses of Member Satisfaction surveys and
all other projects related to member satisfaction, and
identifies areas requiring improvement interventions.
*
Assist Quality Improvement staff in interpretation of Quality
Improvement departmental policies, procedures and criteria for
monitoring and tracking activities. Responsible for monitoring
and evaluating staff performance.
* Implement an integrated
multidisciplinary approach to ongoing monitoring and evaluation
of the quality of health care services. Develop and implement
strategies for oversight of Quality Improvement functions, which
are direct components of the QI Program.
* Develop strategies
for special program participation and Quality Improvement.
Develops systems for close coordination of QI related functions
with departments whose activities are directly a part of the QI
Program, including Credentialing.
* Provide annual budget
preparation and its maintenance within allocated parameters.
* Direct the development, implementation and achievement of
departmental goals. Reviews, modifies/revises processes to
increase productivity and overall department performance.
*
Communicate new state, federal and third party regulations and
requirements to the staff. Acts as a liaison to regulatory
agencies.
Knowledge, Skills and Abilities
* Strong
supervisory and management skills
* Proficiency with computer
information systems and software
* Strong analytical and
problem solving skills
* Project management
* Excellent
verbal and written communication skills
* Maintain regular
attendance based on agreed-upon schedule
* Maintain
confidentiality and comply with Health Insurance Portability and
Accountability Act (HIPAA)
QUALIFICATIONS
Required
Education:
BSN/BS/BA or Degree in Healthcare related field
DIRECTOR OF UTILIZATION
MANAGEMENT - LOS ANGELES, CA
The position's primary
purpose is to assist the Medical Director with complex cases and
to assist with work flow where needed to maximize use of staff
and maintain adherence to timelines and health plan
requirements.
* Evaluates authorization requests for medical
procedures, diagnostic tests, specialty-monitored medications,
surgeries, elective hospitalizations, ancillary services.
*
Determines compliance to pre-established medical necessity
criteria applying Milliman and Robinson, Healthcare Management
Guidelines.
* Suggests alternative treatment/service
appropriate to the patient's condition after reviewing with the
Medical Director.
* Assist the Medical Director in the
triage of all complex cases, including but not limited to: FFS,
tertiary and out of CAP authorizations.
* Communicates with
the Medical Director, and VP Med Ops, daily as to status of
complex cases or new issues.
* Identifies cases requiring
potential or actual use of medically appropriate interventions.
* Interacts with providers for medical information necessary
to adjudicate authorization.
* Assigns specific authorization
Delay Codes when applicable.
* Assigns specific Status Codes
per protocol for each authorization.
* Reviews each
authorization if clinical history supports service/procedure
requested.
* Reviews each authorization for appropriate
requested provider for service area.
* Reviews any potential
denial of service with Medical Director.
* Investigates and
follows up on all additional requests for information by the
Medical Director.
* Primary interface with the physician on
urgent/emergent authorization requests.
* Identify and report
to Quality Management Department any potential quality of care
issue and/or pre-established U.M. Referral Indicators.
*
Clinical resource for Prior-Authorization Coordinators.
*
Educate practitioners as needed with the Authorization/Referral
process.
* Respond to health plan inquiries and requests and
report all submission data in a timely manner.
* Collaborate
with health plan case managers.
* Maintains confidentiality
of all patients and medical/clinical information.
* Performs
as necessary to departmental change, workload and emergencies.
* Assists the Vice President in the annual review process of
P.A. nurses.
* Assists in the development, review and
revision of departmental policies and procedures.
Directly
supervises UM nurses and coordinators in the Utilization
Management Department. Carries out supervisory responsibilities
in accordance with the organization's policies and applicable
laws. Responsibilities include interviewing, hiring, and
training employees; planning, assigning, and directing work;
appraising performance. Active RN license in California
MEDICAL DIRECTOR - HEALTH PLAN -
FL
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.
CLINICAL PHARMACIST - HEALTH
PLAN - SO. CALIFORNIA
* Spearhead and oversee the
implementation of key clinical pharmacy programs.
* Work with
appropriate departments to produce pharmacy related marketing
materials in accordance with CMS guidelines.
* Produce
marketing materials within internally determined timeframes with
accuracy and in accordance with the CMS marketing guidelines.
Utilize CMS model templates to populate pharmacy specific
information per CMS guidelines; partner with Marketing,
Compliance and Member Education as needed.
* Work in
collaboration with other pharmacy staff to support the annual
formulary/ prior authorization (PA) criteria submission to CMS.
* Prepare monographs & prior authorization/ non-formulary
exception criteria and present clinical data on new drug
therapies and clinical programs at Pharmacy and Therapeutics
Committee meetings.
* Work in collaboration with the
pharmacy staff to update and maintain the formulary used by the
Health Plan.
* Review new drugs with the Pharmacy &
Therapeutics Committee within 90-180 days of being marketed.
Decisions related to the drug formulary and utilization
management restrictions will reflect compliance with CMS
guidelines.
* Develop and update Prior authorization criteria
by using appropriate clinical references when new clinical
information becomes available.
* Coordinate the
implementation of new and revised PA/non-formulary exception
criteria with the PBM company.
* Develop and/or implement
clinical pharmacy programs in-house or in collaboration with the
Pharmacy Benefit Management (PBM) company as needed.
PREFERRED QUALIFICATIONS: Pharm.D. Degree with a residency
program in Drug Information or Geriatric Pharmacy preferred .
Pharmacy Licensure in California required . Part D experience
preferred. Managed care experience at a PBM, health plan or
medical group preferred.
Please Contact:
Executive
Search & Placement
Sonia Varian - 818-707-7118, or
espsonia@pacbell.net
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