Regional VP Health Services

Profile

Description

Job Description Summary

The RVP Health Services relies on medical background to create and oversee clinical strategy for the state of Florida. The RVP Health Services requires an in-depth understanding of how organization capabilities interrelate across segments and/or enterprise-wide. The RVP Health Services has accountability for ensuring initiatives that the local Florida health plan, in collaboration with Enterprise Clinical Services and other key Humana stakeholders, focus on clinical excellence, quality improvement, appropriate inpatient and outpatient utilization, affordability, health system transformation, including provider network, compliance with regulatory mandates, growth and other focused improvements to ensure they are implemented and successfully managed to achieve goals. This position reports to the Florida Medicaid Regional President.

Responsibilities

Job Description Summary

The RVP Health Services relies on medical background to create and oversee clinical strategy for the state of Florida. The RVP Health Services requires an in-depth understanding of how organization capabilities interrelate across segments and/or enterprise-wide. The RVP Health Services has accountability for ensuring initiatives that the local Florida health plan, in collaboration with Enterprise Clinical Services and other key Humana stakeholders, focus on clinical excellence, quality improvement, appropriate inpatient and outpatient utilization, affordability, health system transformation, including provider network, compliance with regulatory mandates, growth and other focused improvements to ensure they are implemented and successfully managed to achieve goals. This position reports to the Florida Medicaid Regional President.

Job Description

The RVP, Health Services will provide medical leadership and strategy for the Health Services Operations with fiscal responsibility for trend management.


The RVP Health Services has primary responsibility and accountability for total PMPM performance and targets for the local Humana Healthy Horizon Florida health plan.
Responsibility to oversee clinical model operations and new models of care as required by federal and state requirements.
Additional responsibilities include conducting hospital Joint Operations Committee meetings with high priority targeted providers in coordination with the Humana Network team, data sharing with physicians and physician groups on quality and efficiency improvement opportunities, and implementing local and national Health Care Affordability/Trend Initiatives in order to achieve inpatient and outpatient utilization and affordability goals.
Oversee regional utilization management and case management for inpatient cases (acute care hospital, LTAC, Acute rehab, SNF) according to the Humana's Medicaid policies and procedures.
Participate in Quality Operations including chair Quality Management Committee, complete initial peer review on quality of care and quality of service complaints, complete peer-to-peer written and verbal communications.
Oversees the HEDIS and CMS Stars data collection process and local performance strategy, including but not limited to, quality Improvement and HEDIS/STARS metrics improvement with PCP offices and IPAs, CAHPS improvement strategy, and drive Health Plan accreditation activities as well as quality rating improvement initiatives and other clinical interventions for the local Florida health plan.
Provide oversight and direction for the implementation of regional clinical programs and strategies, as well as, developing and implementing market level strategies.
The RVP Health Services will maintain a strong working knowledge of all government mandates and provisions for the Florida Humana Healthy Horizons market, as well as working across the enterprise to implement and maintain compliant clinical programs and procedures.
S/he also is committed to being effectively engaged with our external constituents such as consumers/members, physicians, medical and specialty societies, hospitals and hospital associations, federal/state regulators, and market-based collaboratives.
RVP Health Services will be the outward face to State regulators based upon Contract, and direction of Plan Regional President and should provide clinical thought leadership with external entities and the state.
Serve as clinical liaison with inpatient facilities and joint operating committees to maintain facility relationship and problem solve; especially reviewing contracts as to clinical services.
RVP Health Services is accountable for the oversight of the entire clinical model (end to end) within the market.
Well-versed on financial aspects of various levels of risk bearing contracts and possess the ability to gain traction and adoption of the providers.
RVP Health Services delivers the clinical value proposition focused on quality, affordability and service, in support of growth activities of Humana Healthy Horizons of Florida.
Participate in regional level committees and meetings setting medical necessity strategies.
Responsible for representing Humana Healthy Horizons of Florida at state-level fair hearings.
Ability to thrive in a highly matrix environment


Required Qualifications


8 or more years of management experience
A current and unrestricted license in the state of Florida
MD or DO degree
Board Certified in an approved ABMS Medical Specialty
5 years of established clinical experience
2-3 years of Quality management experience
Excellent communication skills
Knowledge of the managed care industry including Medicare, Medicaid and or Commercial products
Possess analysis and interpretation skills with prior experience leading teams focusing on quality management, utilization management, discharge planning and/or home health or rehab
Strategic thinking with proven ability to community a vision and drive results
Solid negotiation and conflict management skills
Creative problem-solving skills
Must be passionate about contributing to an organization focused on continuously improving consumer experiences


Preferred Qualifications


Medical management experience, working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.

Experience working with the Medicaid population or Medicaid Managed Care, PEDS, OB-GYN, Drug Abuse/Addiction, or Behavioral Health
Proficiency with Microsoft Office applications.


Scheduled Weekly Hours

40

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