job

About the Organization:

Sentara Health Plans is the health insurance division of Sentara Health, comprised of Optima Health Plan and Virginia Premier Health Plan. Sentara Health Plans provides health insurance coverage through a full suite of commercial products including consumer-driven, employee-owned and employer sponsored plans, individual and family health plans, employee assistance plans, and plans serving Medicare and Medicaid enrollees. With more than 30 years’ experience in the insurance business and 20 years’ experience serving Medicaid populations, Sentara offers programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health services – all to help members improve their health. Learn more at Sentara.com.

About the Position:

This role is responsible for the strategic leadership of behavioral health and addiction recovery treatment services for the health plan. This includes program development, design, outcomes measurement, and evaluation of behavioral health programs for the Medicaid and Medicare lines of business for Optima Health Plan and Virginia Premier Health Plan.

The Senior Director will also have oversight for Sentara Health Plan’s EAP product and program. The primary role of this program is the oversight and operational execution of the Medicaid and Medicare Behavioral Health Utilization Management (UM) and Care Management (CM) Programs in meeting both the DMAS Medicaid requirements but also the Medicare MAPD, DSNP, and CSNP requirements for the end-to-end BH UM and BHCM programs. This position is responsible for meeting all regulatory and accreditation requirements and in meeting clinical, quality, and Clinical Efficiency targets, DMAS PWP, clinical KPIs, and MLR targets.

Responsibilities:

-Oversight and execution of the Health Plans Utilization Management Program and Case Management Programs as defined above

-Performance Management oversight and accountability for both utilization and case management regulatory and operational reporting, production metrics, clinical KPIs, and staff performance and accountability; strong analytic component to role in driving results based on data and trends

-Drive business operations and tactics in support of impacting the MLR and clinical KPIs such as admits and bed days/k, ALOS, medical director referral and denial rates, readmission rates, ER rates and Clinical Efficiency measures/targets, Medicaid PWP measures, Cost of Care tactical ideation and execution, and the BH HEDIS rates

-Achieve new BH NCQA Accreditation

-Responsible for implementation of various new programs, initiatives, and vendor projects and the resultant success thereof
Budget and staff management responsibilities to provide ROIs to support changes in staffing complement or development of new programs

-Responsible for ensuring that all UM and CM regulatory reporting validation is complete and timely; represent results to DMAS/CMS and various audits conducted by DMAS, CMS, NCQA, QI, and internal audit

-Responsible for the success of the UM and CM components of the Medicaid NCQA Accreditation and the Medicaid NCQA LTSS Distinction

-Serve as thought leader to various department leaders, plan presidents, plan vice presidents, and various departments related to all requirements and communications for members and providers related to the utilization management and care management programs

Knowledge:

-Managed Behavioral Health experience required

Qualifications:

-Licensed Registered Nurse (RN)
-Bachelor’s level degree
-Master’s level degree
-Utilization Management: 7 years
-Case Management: 7 years

Position Description »