Virginia Premier Health Plan, Inc.

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Sr. Manager Health Services (MAPD)

Sr. Manager Health Services (MAPD)

Job Locations 
US-VA-Glen Allen
Job ID 
2017-4151

Job Description

Overview

The Sr. Manager, Health Services (MAPD) is responsible for assisting with program development and providing direct supervision of the Medicare Advantage Plan (MAPD) staff for daily clinical decisions and monitoring of individual performance and compliance with VA Premier Health Plan (VPHP) policies and procedures.  The Sr. Manager is also responsible for identifying and delivering clinical process improvements for the VPHP MAPD.  This position is part of the Medical Management team in Richmond, VA.

Medical Management educates members and empowers them to become active participants in their coordinated health care plans.  This team of knowledgeable professionals in their field provide services to include Utilization Review, Medical Outreach, Case Management, Disease Management, Credentialing, Social Work as well as Grievance and Appeals.

Responsibilities

  • Supervises management staff designated for the VPHP MAPD program according to VPHP’s policy and procedures to assure that clinical operations and activities are accurate, consistent, and performed in a timely manner
  • Works with  medical management  staff to provide guidance and/or intervention in  problematic or 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
  • Assists AVP, Population Health in ongoing Quality Improvement Programs 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
  • Ensures business processes are in place to monitor and manage the VPHP MAPD 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
  • Assists with development of policy, procedure, standard operating procedure, workflow, job aids, and training materials for VPHP MAPD or other health plan initiatives
  • Drives program deployment: understands strategies and issues, drives plans, ensures smooth transitions
  • Defines, documents and prioritizes change impacts for clinical programs across functions
  • Works with the Senior Leadership team to gain approval for program enhancements
  • Maintains current knowledge of VPHP and VPHP MAPD policies and procedures
  • Participates in community programs (which may occur outside of normal business hours)
  • Responsible for the duties of the Manager/Supervisor in the absence of these positions

Qualifications

MINIMUM EDUCATION REQUIREMENTS

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

SPECIAL KNOWLEDGE AND/OR SKILLS

  • Knowledge of project management and process improvement methodology
  • 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
  • Ability to foster collaboration with internal and external partners
  • Proficient use of Microsoft applications
  • Possess knowledge of ICD 10 and CPT4 coding

WORK BACKGROUND/EXPERIENCE

  • Minimum of 3 years of experience with Medicare OR Medicare Advantage Programs
  • Case management experience, preferably in a managed care environment
  • Minimum of 3 years of management experience
  • Experience with program development and implementation
  • Experience with contracts/performance measures
  • Experience in Medicaid and Medicare managed care
  • Knowledge of STARS and HEDIS measures
  • Experience working with the frail and elderly and disabled populations
  • Solid leadership experience to lead a team comprised of clinical and non-clinical roles

 

 

PHYSICAL REQUIREMENTS

  • Physical health sufficient to meet the ergonomic standards and demands of the position.
  • Ability to travel throughout the state for stakeholder meetings/conferences, training, and oversight of assigned regional offices.

 

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!

 

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. 

 

Equal Opportunity Employer
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.

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