Virginia Premier Health Plan, Inc.

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Director, Health Services (MLTSS)

Director, Health Services (MLTSS)

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Job Description


The Director of Complete Care Health Services is responsible for the strategic implementation and development and the oversight of operations in collaboration with the AVP.  The Director coordinates duties with appropriate personnel to meet operational program needs, ensures compliance with state and federal health plan requirements, Medicare  and Medicaid guidelines.  The Director will assist senior leadership with long-term planning initiatives to maintain operations assuring activities are appropriately integrated into strategic direction, as well as the mission and values of the company.



  • Responsible for planning and implementing assigned regional market success initiatives with each region’s team
  • Oversees the Health Services’ Department and staff role s and responsibilities
  • Works with  medical management  staff to provide guidance and/or intervention in problematic/unusual cases in all office locations
  • Serves in an advisory capacity for problem solving, reviewing reports being sent to internal and external customers, reviewing problematic cases, and monitor case management activities
  • Maintains resources, keeping information up-to-date
  • Participates in public speaking presentations and community education initiatives on behalf of VPHP CompleteCare as needed
  • Assists AVP of CompleteCare Services in ongoing Quality Improvement Program by assisting with various quality review tasks such as collecting and analyzing data as outlined in the program
  • Assists in the ongoing development of programs and medical management projects to enhance/expand the medical management department
  • 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 CompleteCare operational processes as defined by the state contract and/or national standardized model components
  • Develops, implements, and monitors clinical processes metrics and monthly report card
  • Analyze 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, ensures smooth transitions
  • Define, document and prioritize change impacts for clinical programs across functions
  • Develops and maintains strong working relationships with both internal and external stakeholders
  • Works with the Senior Leadership team to gain approval for program enhancements
  • Provides training, mentoring and coaching where appropriate
  • Maintains current knowledge of VPHP and CompleteCare policies and procedures
  • Participates in community programs (which may occur outside of normal business hours)



  • Minimum education degree of Bachelors of Science in a health care field
  • License/Certification – Current Registered Nurse licensed to practice nursing in Virginia - Certified Case Manager (CCM), preferred


  • Patient assessment skills
  • Knowledge of community resources and vendor options and experience in making appropriate referrals
  • Ability to negotiate with providers, vendors and care providers
  • Ability to communicate effectively verbally and in writing
  • PC literate
  • Possess knowledge of ICD-9 and CPT4 coding


  • Case management experience, preferably in a managed care environment
  • Minimum of 2 years of management experience
  • Experience in Medicaid and Medicare managed care
  • Demonstrates excellent verbal and written communications
  • Demonstrates working knowledge of computers and MS office programs
  • Experience working with low income disadvantaged and elder populations


  • Physical health sufficient to meet the ergonomic standards and demands of the position.

About Us


Virginia Premier Health Plan, Inc. 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 Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 


We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  


Our mission is to inspire healthy living within the communities we serve!

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