Director, Health Services – DSNP

The Director of Health Services DSNP is responsible for the strategic implementation, program development, and oversight of clinical operations for both the CCC Plus and Dual Special Needs Programs (DSNP) in collaboration with the Associate Vice President (AVP) of Health Services.  The Director coordinates duties with appropriate personnel to meet operational program needs, ensures compliance with state and federal health plan requirements, makes recommendations for program enhancements to improve care delivery, ensures compliance with NCQA guidelines, and provides leadership presence to the DSNP care management team.  The Director will assist senior leadership with long-term planning initiatives to maintain operations assuring activities are appropriately integrated into the overall strategic plan for the organization. The Director works collaboratively with the AVP and the Vice President for Federal Programs to increase membership in the DSNP line of business.

Essential responsibilities include but are not limited to:

Responsible for planning and implementing program and department specific success initiatives within the care management teams.
Contributes to Virginia Premier’s strategy and business goals, and is a key representative of the clinical model of care on select committees, meetings and workgroups.
Monitor clinical program metrics and trends, while supporting process improvements to preserve program integrity and clinical efficacy.
Provides continuous monitoring of the DSNP model of care program metrics, both CCC+ (DMAS) and CMS requirements, quality initiatives, operational dashboards, adherence to established policy, service level standards and any other associated regulatory compliance and/or accreditation requirements.
Develop and maintain the DSNP Model of Care.
Works with medical management staff to provide guidance and/or intervention in problematic/unusual cases.
Supports company-wide initiatives within the Virginia Commonwealth University enterprise and with external entities.
Serves in an advisory capacity for problem solving, reviewing reports being sent to internal and external customers, reviewing problematic cases, and monitor case management activities.
Maintains resources, keeping information up-to-date – including policies, standard operating procedures, Model of Care, training documentation, and other department documents.
Participates in public speaking presentations and community education initiatives on behalf of Virginia Premier as needed.
Assists AVP of Health Services in ongoing Quality Improvement initiatives by assisting with various quality review tasks such as collecting and analyzing data as outlined in the program.
Ensures program processes and policies are aligned with all regulatory compliance and/or accreditation requirements – including NCQA requirements.

MINIMUM EDUCATION REQUIREMENTS

Minimum education degree of Bachelors of Science in a health care field.
License – Current Registered Nurse licensed to practice nursing in Virginia.
Certified Case Manager (CCM) preferred.

SPECIAL KNOWLEDGE AND/OR SKILLS

Highly motivated individual with the ability to work independently as well as part of a team
Possess a strong understanding of the healthcare industry, managed care organizations, Medicare Special Needs Plans, Medicaid, and Long Term Support Services (LTSS)
Excellent verbal and written communication skills
Knowledge of NCQA and HEDIS
Demonstrated knowledge of Case Management principles
Strong analytical problem-solving, time management, and organizational skills
Proficient Microsoft Office product computer skills
Knowledge of community resources and vendor options and experience in making appropriate referrals
Ability to negotiate with providers, vendors and care providers
Knowledgeable in process improvement methodology such as LEAN and Six Sigma
Knowledge in program start-up and/or enhancements

WORK BACKGROUND/EXPERIENCE

Minimum of 5 years of case management experience preferably in a managed care setting
Minimum of 5 years of management experience
Knowledge of utilization management, preferably service authorizations related to waiver services
Minimum of 2 years of experience in Medicaid and Medicare managed care

PHYSICAL REQUIREMENTS

Physical health sufficient to meet the ergonomic standards and demands of the position.
Regular local & state travel will be required

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