At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life. Our mission is to inspire healthy living within the communities we serve!
All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.
If this sounds like you, read on!
The Director of MLTSS (Waiver Population) is responsible for the strategic implementation, program development, and oversight of clinical operations for the waiver services in collaboration with the Vice President 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 in the satellite offices throughout the state. 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.
Key responsibilities include but are not limited to:
Responsible for planning and implementing assigned initiatives with each region’s team.
Oversees the CCC Plus Program for members with CCC+ and nursing facility waivers and staff roles and responsibilities.
Works with care coordination staff to provide guidance and/or intervention in problematic/unusual cases in all office locations.
Supports company-wide initiatives within the VCU 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 care coordination activities.
Assists VP 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.
Represents the department in key stakeholder meetings.
Ensures program processes and policies are aligned with NCQA standards.
Assists in the ongoing development of programs and medical management projects to enhance/expand the care coordination program.
Independently research and determine the information necessary to satisfy specific business and regulatory medical management requirements.
Ensures business processes are in place to monitor and manage the CCC Plus operational processes as defined by the state contract and/or national standardized model components.
Monitors and tracks program metrics, dashboards, and other reporting tools to drive action and improvements.
Analyzes data to identify under/over utilization; improve resource consumption; promote potential reduction in cost; and enhance quality of care consistent with health plan’s strategic goals and objectives.
Solves unique and complex problems with broad impact on the business.
Drives program deployment: understands strategies and issues, drives plans, and ensures smooth transitions.
Define, document and prioritize change impacts for clinical programs across functions.
Provides training, mentoring and coaching for direct and indirect reports.
MINIMUM EDUCATION REQUIREMENTS
Current Registered Nurse licensed to practice nursing in Virginia OR Licensed Clinical Social Worker required
Bachelors of Science in a health care field preferred
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
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 of utilization management, preferably service authorizations related to waiver services.
Knowledge in program start-up and/or enhancements
Minimum of 5 years of case management experience preferably in a managed care setting
Minimum of 5 years of management experience
Minimum of 2 years of experience in Medicaid or Medicare managed care, preferably with the CCC+ and nursing facility waiver members.
Physical health sufficient to meet the ergonomic standards and demands of the position
Virginia Premier is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs. Headquartered in Richmond, VA we also have offices in Bristol, Roanoke, Tidewater, Winchester and Arlington allowing us to serve over 200,000 members across eighty counties throughout Virginia.