• Neighborhood Health Plan
  • $108,380.00 -167,060.00/year*
  • Somerville , MA
  • Executive Management
  • Full-Time
  • 5 Walnut St


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A career at AllWays Health Partners is you in every way! Inspired by our affiliation with Partners HealthCare, our promise as a people-first organization starts with our employees. Get inspired to bring your unique talents to our diverse community and challenge the health care industry status quo with innovative programs that put people first. Our perks include a competitive benefits package, access to world-class doctors, and more.

Directs day-to-day operation of Medicaid ACO programs including timely completion of MassHealth deliverables; strategic initiatives in collaboration with Merrimack Valley ACO; liaison with MassHealth Leadership; oversight of quality metric performance; and management of financial performance.

The Vice President will also be accountable for oversight of the pharmacy benefit manager including financial performance, formulary management, drug management programs, and supervision of utilization management performance. Works with the Director of Pharmacy to develop and implement strategic pharmacy programs that meet the needs of accounts.

Responsibilities will also include supervision of the patient assignment unit which identifies potential candidates for population health management. Oversees productivity of the PAU and reliability of predictive analytics.

Provides cross-organization representation of Clinical Services on specific initiatives and committees.

Provides strategic direction and oversight of clinical vendor relationships. These relationships may include the pharmacy benefit manager, utilization management vendors, and/or behavioral health vendors. The VP, Clinical Operations is responsible for annual reviews of vendor performance and make recommendations based on data analytics.

Responsible for completing work in a timely manner. Work will meet compliance requirements for Division of Insurance, MassHealth, the Massachusetts Health Connector, NCQA and departmental standards. Must be able to manage competing priorities and have the ability to multi task. Must be flexible to meet the business needs of the department when working on special or high priority projects and when volume of work is temporarily increased.

Supervises the Director of Sales Support to ensure that clinical products are designed to meet the needs of accounts. Ensures that clinical reports for accounts accurately reflect the value of AllWays Health Partners programs. In addition, the VP Clinical Operations will support relationships with network providers and oversee the development and quality of reports generated for risk-bearing providers.

Essential Functions

Staff Management and Leadership

* Effectively deploy allocated resources
* Business Planning
* Oversee UM clinical managers/supervisors in staff performance management
* Staff growth and development
* Internal and external communication on a team and individual basis
* Maintain documentation audit process & required reporting
* Support integration of new clinical programs with network practices and shared risk arrangements and service vendors

Infrastructure Enhancement

* Participate in system enhancement planning & development
* Policy & Procedure implementation and maintenance
* Provide ongoing and actionable communication to internal departments (contracting, credentialing, clinical leadership, member services)
* Promote professional practice standards
* Facilitate identification of AllWays Health Partners systems opportunities to Clinical workflow
* Ensure effective Policy & Procedure development, maintenance and implementation
* Conduct benchmarking and research to make new technology assessments and recommendations
* Lead short term projects related to completing RFRs and modifying the clinical components of key organizational tools such as the Provider Manual and the Member Handbook
* Lead system evaluation, enhancement planning, development, and implementation to meet the needs of the business
* Lead practice integration initiatives, supports case finding, and collaborates with network practices to support high quality service to members
* Direct care management system maintenance from a business perspective, and supports technical maintenance efforts

Clinical Compliance

* Maintain compliance with all UM and QM standards, contractual and Regulatory requirements
* Ongoing assessment of performance, Mock audits, Anticipate new standards, Planning for compliance, Compile binders and Maintain site visit preparation materials, Provider Satisfaction Survey, Over/Under Utilization oversight, UM program description, Coordinate DOI submissions for clinical, Coordinate MassHealth submissions for clinical, Advising clinical leadership in operational changes and recommendations for change based on survey findings, regulatory or contractual change.
* HVMA Delegation Compliance ongoing assessment of performance, Communicate new standards, Compile and Maintain site visit preparation materials
* Leverage contracts and manage relationships with the Hayes Directory, Inc and the External Physician Review to conduct Medical Necessity and Technology review tool evaluation.

Quality Assurance

* Oversees Quality Assurance auditing for Utilization Management and Care Management
* Identifies opportunities for process improvement to support care management staff proficiency and communicates with business partners

Regulatory Reporting

* Leads Clinical participation in MassHealth Quality Improvement Goal data retrieval and reporting

Analytics

* Oversees Clinical Analysis to support department initiatives
* Directs clinical data identification and retrieval to support MassHealth Quality Improvement Goals, program evaluations, and NCQA reports
* Responsible for data analysis and trending related to clinical reporting tools
* Maintains Clinical Dashboard

Training

* Oversees care management system (CCA), Clinical QNXT and predictive algorithm training support
* Supports staff training on InterQual/CERME

Other

* Responsible for completing work in a timely manner. Work will meet compliance requirements for Division of insurance, MassHealth, NCQA and departmental standards. Must be able to manage competing priorities and have the ability to multi task. Must be flexible to meet the business needs of the department when working on special or high priority projects and when volume of work is temporarily increased.
* Anticipates and meets, or exceeds, internal and/or external customer expectations and requirements; establishes and maintains effective relationships with customers and gains their trust and respect.
* Serves as/coordinates participation of subject matter experts in corporate projects
* Leads and/or coordinates special projects as assigned
* Anticipates and meets, or exceeds, internal and/or external customer expectations and requirements; establishes and maintains effective relationships with customers and gains their trust and respect.
* Interacts with network leaders on integration and informatics efforts
* Works as a team player who prioritizes welfare of the organization over individual ambitions
* Inform, engage, inspire, motivate, and actively listen to employees.
* Make decisions that put the needs of the people we serve-our members, providers, brokers, and employers-front and center.
* Communicate and cascade information to employees in a timely manner and actively participate in the success of cross-organizational programs and initiatives.
* Identify/create processes and align resources to accomplish key objectives; clearly convey and assign clear accountability for important objectives, deadlines, and expectations.
* Hire, participate in, and/or recommend development measures and disciplinary actions up to and including termination; evaluate performance and supervise the work of all direct and indirect reports following established organizational policies, procedures, and practices.
* Set clear goals and objectives, use metrics to measure performance, and hold employees accountable. Provide coaching to improve performance and holds regular development meetings.
* Ensure diversity, equity, and inclusion are integrated as a guiding principle.
* Hold self and others accountable to meet commitments.
* Persist in accomplishing objectives to consistently achieve results despite any obstacles or setbacks.
* Build strong relationships and infrastructures that designate AllWays Health Partners as a people-first organization.

Management Responsibilities

* Hires, participates in and/or recommends development measures and disciplinary actions up to and including termination, evaluates performance, and supervises the work of all direct and indirect reports following established organizational policies, procedures, and practices.
* Motivates and encourages staff; leads through change and adversity. Makes decisions as needed and builds consensus as appropriate. Communicates and cascades information to employees in a timely manner and actively participates in the success of cross-organizational programs and initiatives.
* Sets clear goals and objectives and uses metrics to measure performance and hold staff accountable. Provides coaching to improve performance and holds regular development discussions with direct reports. Recognizes staff for their contributions.
* Directs management staff comprising of Clinical Informatics Manager, Clinical Quality Assurance Manager, and Clinical Senior Analyst.
* Other duties as assigned with or without accommodation.
* Work is normally performed in a typical office work environment.
* Oversees the Clinical Managers for Inpatient and authorization management
* Works collaboratively with Clinical Directors, Clinical Managers, and Medical Directors
* Establishes and maintains relationships with Provider Network Management, Claims Management, Finance Management, Customer Care Management, Hospital UM/CM Staff, and Delegated entities

Required:

* Bachelor's Degree or the equivalent combination of training and experience, plus 15 - 20 years of related clinical experience.
* Valid Unrestricted RN licensure in Massachusetts required
* 15-20 years' experience which includes 3-5 years managed care experience, 3-5 years supervisory/management experience, and 3-5 years of experience with benefit and contract management, utilization management.
* Experience with regulatory reporting
* Experience with clinical technical systems
* Experience with business process design/redesign

Preferred/Desired:

* Master's Degree in Nursing, Management, Public Health, Business
* Experience with Medicaid, Medicare and Commercial products
* Demonstrate AllWays Health Partners' core brand principles of always listening, challenging conventions, and providing value.
* Bring fresh ideas forward by listening to and working with employees and the people we serve.
* Respect the talent and unique contributions of every individual and treat all people in a fair and equitable manner.
* Strong, demonstrated track record of an ability to execute on time, on budget, and on scope.
* Strong aptitude for technology-based solutions.
* Ability to inject energy, when and where it's needed.
* Excellent leadership skills and leadership track record.
* Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience; strong executive presence, presentation and communication skills. Strong verbal, active listening, and written communication skills required.
* Excellent interpersonal skills, including the ability to influence others at all levels of an organization.
* Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
* Unquestionable integrity.
* Excellent organizational and analytical skills.
* Excellent judgment and decision making abilities.
* Strong influencing skills and perseverance
* Ability to develop and motivate employees to meet departmental and organizational objectives.
* Ability to manage multiple projects, meet deadlines and nimbly adjust to changes in company policies, procedures and priorities
* Ability to develop, introduce, defend, and gain support for a new ideas and approaches.
* Pre-employment background check
* CORI background check, if applicable
* Project management, benefit & contract management, presentation development and compliance
* Competence in program strategy and measurement
* Experience with presentation development & delivery
* Advanced proficiency in Windows platform, including Word, Excel, PowerPoint
* Ability to function in multiple application products
Associated topics: administrative assistant, administrative coordinator, administrative officer, administrative support, assistant, associate, beverage, document, front office, operational support

* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.

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