VP Health Plan Clinical Programs

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Position Summary
The Vice President Health Plan Clinical Programs provides strategic clinical and operational leadership in the Health Plan in the development and evaluation of systems of health care that improve the member experience and health outcomes and provides stewardship of resources consistent with Martin’s Point goals.

This position works closely and collaboratively with peer Vice Presidents in the Health Plan and other leaders across the organization to support the business success of and experience of members in Martin’s Point Health Plans.

Additionally, the VP HP Clinical Services will play a key role in the strategy and deployment of the integration of Health Plan programs with the Delivery System and external provider partners to ensure mutual success.
The VP HP Clinical Programs will be responsible for leading the strategic direction and integration of cost of care, pharmacy, and quality programs and operations for Martin’s Point Health Plans.

This executive will work closely with all functional areas of the organization (e.g., provider relations, compliance, operations, product management, delivery system, finance) to ensure the successful management of medical and pharmacy expense, and quality across the Health Plan.

Job Description

Key Outcomes:
Leads strategic efforts for Martin’s Point’s Health Plan and Practice Pharmacy Operations and Clinical Programs, ensuring compliance with DoD, Medicare, and State & Federal Pharmacy requirements and programs address the current pharmacy environment.
Responsible for the overall strategic direction and oversight of Health Plan Quality and Safety programs and activities, including Star Ratings, HEDIS, health plan current and future accreditation, and other CMS, DHA, and regulatory/accreditation requirements (e.g., QIPs, Annual Quality Plans/Programs).
Ensures the integration and exemplary performance of clinical programs (medical management, quality, and pharmacy) to support improved care, profitability, and extraordinary member experience for Martin’s Point Health Plans, shared patient/member population and to support expansion into other populations/products.
Responsible for strategic oversight of the Health Plan medical management program, including medical expense management, utilization management, care/case management, and other clinical programs.
Serves as a strategic partner with Martin’s Point Delivery System leadership to create alignment between medical management, quality, and pharmacy initiatives.
Provides strategic guidance for the development of population-based clinical intervention and measurement of success.
Institutes processes for continuous evaluation of trends related to medical expense, pharmacy, quality measures and clinical and operational program performance and identifies and takes action on opportunities for improvement.
Partners with VP, Health Plan Products to ensure medical expense, and pharmacy performance supports overall product performance and profitability for Martin’s Point Health Plans and provides support for product development process.
Partners with VP, Network Management to provide strategic support for development of provider payment models and manage cost of care, clinical, pharmacy and quality improvement through network relationships by providing insights into performance data and collaboration on key programs.
Ensures appropriate and effective care management programs for all Health Plan products.
Partners with the Chief Medical Officer in leadership and oversight of the Health Plan Medical Director team, including strategies to manage cost and quality of care.
Responsible for oversight of the Health Plan Quality committee structure and performance and the member and provider appeal processes.
Oversees performance goals for pharmacy programs including pharmacy expense trends, member satisfaction with health plan pharmacy programs, performance of clinical programs, and pharmacy operational performance.

Tracks and analyzes performance and advocates for change, where necessary, to meet Martin’s Point’s strategic goals with a strong understanding of its mission to provide superior care and service to its customer base.

Key contributor to strategy development for and execution of new and financially viable products.

Provides guidance, leadership and direction to ensure the organization’s strategic plan is translated into tactical goals and expectations that guarantee performance objectives are met or exceeded.
Maintain an open dialogue with the compliance team to ensure the regulatory constituents are satisfied with Martin’s Point’s performance and the organization is compliant with all regulations.

Review and keep abreast of regulatory changes for all Health Plan products and programs to ensure proper communication around such regulatory changes.

Ensure compliance with applicable regulatory and internal requirements, including product reports for the department and other internal or external clients, regulators, and accrediting bodies.
Manage and coach Health Plan management and staff to perform effectively, as a team, to support MP strategies with an intense focus on continuous improvement and proactive problem solving.

Effectively promotes and manages change, while developing staff to provide leadership to the organization, increase bench strength, including collaboration with staff to develop individual career paths and succession plans.
Education/Experience:
Bachelor’s degree required; Master’s preferred
10+ years of related experience including managed care and leadership
Demonstrated experience working with Clinicians to deploy best clinical practices
Required License(s) and/or Certification(s):
Clinical licensure preferred (MD, DO, RN, NP, PA, Pharm.D.

or similar level clinical licensure)
We are an equal opportunity/affirmative action employer.

Do you have a question about careers at Martin’s Point Health Care?

Contact us at: jobinquiries@martinspoint.org
Full time