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CVS Health Kentucky, Alabama

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Search by job title, category, or Military MOS code Medical Director – Behavioral Health (Aetna Medicaid) Job ID: 1771898BR Category: Medicaid Address: Location: Louisville, KY Job Description We are currently seeking a Behavioral Health Medical Director for Aetna Better Health of Kentucky, supporting Aetna Medicaid Region 3 (Florida, Kentucky and Louisiana) as well as behavioral health coverage for any of the Medicaid plans as needed. The successful candidate will be responsible for providing clinical expertise and business direction in support of the medical management programs, including clinical review, case and quality management. The Medical Director will act as a liaison to external customers and regulatory agencies. Summary: Aetna Medicaid has a model of care: To collaborate with the people we serve to integrate physical and psychosocial wraparound services based on a bio-psychosocial understanding of our member’s lives. Essential Responsibilities: • Be committed to the Medicaid/underserved population, and to the principle that helping Medicaid members improve their health will drive lower costs and produce a return on investment for state Medicaid programs. • Be committed to promoting recovery and enhancing resiliency for all members. • Be comfortable working with data in collaboration with subject matter experts. • Provide clinical expertise and business direction in support of medical management programs through participation with clinical teams in activities of precertification, concurrent review/discharge planning, case management, disease management, quality management and clinical claim review. • Provide clinical guidance in operating effective medical management programs. • Oversee triage and referral for behavioral health staff. • Participate in quality management activities, including committee and accreditation needs. • Lead clinical staff in assuring members care is coordinated in a fashion that achieves the most value for the available benefit. • Act as a clinical liaison to state agencies and external provider community in general. • Be comfortable in working in a fast-paced, fluid, high-energy environment where all team members are accountable for creating high quality work products, where cross-functional teamwork is routine, and where rapid-cycle development is required to meet market demands. Aetna operates Medicaid managed care plans in sixteen states: Arizona, California, Florida, Illinois, Kansas, Kentucky, Louisiana, Maryland, Michigan, New Jersey, New York, Ohio, Pennsylvania, Texas, Virginia and West Virginia. Required Qualifications -2 or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry. -Active and current Kentucky state medical license without encumbrances -M.D. or D.O., Board Certification in a ABMS recognized specialty including post-graduate direct patient care experience. -Experience working with individuals with serious/severe mental illness, disabling substance use disorders, or developmental disabilities, etc COVID Requirements COVID-19 Vaccination Requirement CVS Health requires its Colleagues in certain positions to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, pregnancy, or religious belief that prevents them from being vaccinated. If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 30 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 60 days of your employment. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health. If you are unable to be fully vaccinated due to disability, medical condition, pregnancy, or religious belief, you will be required to apply for a reasonable accommodation within the first 30 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. If your request for an accommodation is not approved, then your employment may be terminated. Preferred Qualifications Healthcare Insurance experience Managed Care experience Education -Active and current state medical license without encumbrances -M.D. or D.O., Board Certification in a ABMS recognized specialty including post-graduate direct patient care experience Business Overview At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart. We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities. Apply A workplace that supports diversity, inclusion and belonging. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, sex/gender, sexual orientation, gender identity or expression, age, disability or protected veteran status or on any other basis or characteristic prohibited by applicable federal, state, or local law. We comply with the laws and regulations set forth in the following EEO is the Law Poster: EEO IS THE LAW (PDF) Opens in a new window and EEO IS THE LAW SUPPLEMENT Opens in a new window . Please note that we only accept applications for employment via this site. We provide reasonable accommodations to individuals with disabilities as needed. To request an accommodation – including a qualified interpreter, written information in other formats, translation or other services – please email AdviceandCounselcvshealth.com or call 877-805-9511 . If you have a speech or hearing disability, please call 7-1-1 to utilize Telecommunications Relay Services (TRS). We will make every effort to respond to your request within 48 business hours and do everything we can to work towards a solution. The health and safety of our employees, patients, customers, and members is our top priority as we face the impact of COVID-19 together. We encourage you to visit our COVID-19 resource center to learn more. About CVS Health CVS Health is the leading health solutions company that delivers care in ways no one else can. We help people navigate the health care system — and their personal health care — by improving access, lowering costs and being a trusted partner for every meaningful moment of health. And we do it all with heart, each and every day. We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status.

 
 

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The Ohio Department of Medicaid (ODM) is committed to improving the health of Ohioans and strengthening communities and families through quality care. In 2020, ODM introduced a new vision for Ohio’s Medicaid program — one that strengthens Ohio’s future and ensures everyone has the chance to live life to its full potential.


Today, more than 90 percent of Ohio Medicaid members are supported by managed care organizations. During the year ahead, ODM will begin implementing a new vision for care; focusing on the individual, a strong partnership among MCOs and the department, and supporting specialization in addressing critical needs.


A program that puts the individual first


They Are


Adopting Governor DeWine’s philosophy of service to Ohioans, ODM embarked on an aggressive effort to redesign its managed care program. The goal is to provide more personal, holistic care and supports for millions of Ohioans served by Medicaid. Listening to feedback from more than 1,100 individuals and organizations we identified five procurement goals that would put the individual front and center of Medicaid’s program and policy decisions.

• Emphasize a personalized care experience
• Improve care for children and adults with complex behavioral health needs
• Improve wellness and health outcomes
• Support providers in better patient care
• Increase program transparency and accountability
  
  

UNLESS REQUIRED BY LEGISLATION OR UNION CONTRACT, STARTING SALARY WILL BE SET AT STEP 1 OF THE PAY RANGE


Office: Operations


Bureau: MITS & Systems Operation


Classification: Business Process Analyst 1 (PN 20093908)


Job Overview


The Ohio Department of Medicaid (ODM) is seeking to fill a position in its MITS & Systems UAT unit. The position will support ongoing User Acceptance Testing (UAT) for system enhancements and defects. As a User Acceptance Tester, your responsibilities will include:

• participating in User Acceptance Testing (UAT)
• developing User Acceptance Testing cases and scripts
• utilizing test management tools
• analyzing business requirements and design documents
• coordinating and providing training to business areas
• gathering and identifying relevant documentation for test script development
• compiling intermittent activity and testing status reports or ad hoc statistical reports
  
  

The preferred candidate will have extensive testing knowledge and strong analytical skills.


Completion of undergraduate core program in computer science, information systems, or business administration; 12 mos. combined work experience in any combination of the following: creating and coordinating technical and business requirements for processes, projects and procedures, working with business users and technical staff to develop strategies and leading modification or creation of new systems for implementation of information technology solutions.

• Or completion of associate core program in computer science or information systems; 18 mos. combined work experience in any combination of the following: creating and coordinating technical and business requirements for processes, projects and procedures, working with business users and technical staff to develop strategies and leading modification or creation of new systems for implementation of information technology solutions.
• Or 36 mos. combined work experience in any combination of the following: creating and coordinating technical and business requirements for processes, projects and procedures, working with business users and technical staff to develop strategies and leading modification or creation of new systems for implementation of information technology solutions.
• Or equivalent of minimum class qualifications for employment noted above.
  
  

Primary Location


United States of America-OHIO-Franklin County-Columbus


Work Locations


Lazarus 4


Organization


Ohio Department of Medicaid


Classified Indicator


Classified


Bargaining Unit / Exempt


Bargaining Unit


Schedule


Full-time


Work Hours


8:00AM – 5:00PM


Compensation


$28.80/hour


Unposting Date


Oct 5, 2021, 11:59:00 PM


Job Function


Information Technology


Job Level


Individual Contributor


Agency Contact Information


HumanResources@medicaid.ohio.gov

 
 

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MACPAC, a nonpartisan federal legislative branch micro agency that provides policy and data analysis to Congress regarding Medicaid and the State Children’s Health Insurance Program (CHIP), is seeking a chief information officer (CIO) to lead its small information technology (IT) team. The CIO performs macro-level agency duties as well as day-to-day network and user support duties required to ensure the confidentiality, integrity and availability of MACPAC’s network, computing and communications systems. This position has supervisory responsibilities and reports to the chief operations officer.


Major Duties


The CIO Will Provide And Implement The Strategic Vision For MACPAC Technology Resources, Ensure Its Information Resources Are Secure, And Provide Oversight And Management Of All MACPAC Technology Operations To Also Include, But Not Limited, To The Following

• develop goals and objectives for technology and information initiatives for MACPAC based on organizational needs;
• ensure the protection of IT assets and the integrity, security, and privacy of information entrusted to or maintained by MACPAC;
• develop and maintain information technologies policies and procedures, and associated documentation;
• provide advice and counsel concerning IT issues and industry trends to agency leadership;
• research, develop, and implement new services that can improve efficiency of MACPAC through the use of information systems;
• develop, plan, and manage the annual MACPAC information and technology resources and budget in consultation with leadership;
• work closely with all staff regarding technology needs and requests;
• ensure incident resolution in a timely manner;
• identify, develop, and manage vendors to provide MACPAC with necessary technology and information resources and services;
• ensure that all licensing and maintenance agreements are current;
• develop and implement technology and information disaster recovery strategies;
• supervise and direct the work of the senior information technology specialist and contract-based technical personnel;
• manage IT vendor contracts;
• manage the security and storage of sensitive statistical information in compliance with appropriate laws and data use agreement;
• Conduct annual IT policies, security controls and security reviews consistent with NIST guidance;
• Perform day-to day user, network, server and application support using a ticketing system and support application; and
• Perform other duties as assigned.
  
  

Knowledge and Skills


To perform the major duties listed above, the chief information officer must have:

• ability to assess agency evolving IT requirements, plan and implement technology improvements;
• strong knowledge of internal controls, risk assessment and security best practices per NIST guidance;
• ability to prioritize and manage multiple competing responsibilities and tasks;
• ability to balance macro-level agency duties as well as micro-level day-to-day network and user support;
• strong oral and written communication skills;
• an orientation toward problem solving, teamwork, and accountability;
• experience with cloud-based solutions and architectures, such as Amazon Web Services;
• ability to see color and to distinguish letters, numbers and symbols.
• ability to occasionally climb a ladder or stool, crawl or crouch on the floor, and lift and move up to 45 pounds; and
• willingness to engage in learning and development.
  
  

Qualified candidates should have a bachelor’s degree in a related field, with a master’s degree preferred and at least 10 years of experience performing duties listed above.

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Description:

One Mission. More Than Half a Million Reasons.
As we empower every New Yorker
to live the healthiest life possible.

Job Ref: 64923

Category:
Professional

Department:
OPERATIONS EXCHANGE
Location: 50 Water Street, 7th Floor, New York, NY 10004
Job Type:
Regular

Employment Type:
Full-Time

Hire In Rate:
$135,000.00

Salary Range:
$135,000.00 – $140,000.00

About NYC Health + Hospitals

MetroPlus Health provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc.

As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics.

For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

Reporting to the Head of Product, the Director of Medicaid ensures operational excellence and regulatory compliance of all Medicaid products, owning the full spectrum of product strategy and operations.

The Director will support key analytical activities to support the Plan’s strategic position, and will be proactive in identifying opportunities for performance improvement.

Job Description

 

• Provide oversight of Plan and vendor operations as they relate to the Medicaid line of business aligning outcomes to strategic goals & regulatory requirements.
• Develop & manage operational reports to track operational effectiveness.
• Partner with operational departments including Claims, Customer Service, Finance, Enrollment, Vendor Management, & Medical Management to design processes ensuring effective & efficient operations.
• Support key stakeholders in driving initiatives to meet quality & customer satisfaction goals.
• Maintain customer focus throughout Plan operations to ensure a seamless & excellent customer experience.
• Provide deep knowledge of & insight into the regulatory & market environment of Medicaid in New York to support the development of product strategy.
• Identify & integrate operational best practices, partnering with key departments to optimize processes across the organization such as benefits administration, risk adjustment, marketing & communications, customer experience.
• Monitor & analyze regulatory activity ensuring compliant operations & implementation.
• Perform competitive & market analysis.
• Partner with internal & external stakeholders on key strategic, regulatory, & operational projects.

Minimum Qualifications

 

• Bachelor’s degree from an accredited college or university in an appropriate discipline required.
• Master’s degree in business, healthcare or public administration strongly preferred.
• Minimum 5 years experience at a Health Plan with Medicaid Managed Care in a product management or compliance role.
• Thorough knowledge of Medicaid regulatory environment in NYS.
• Experience working with NYS enrollment transactions & encounter data submissions.
• Thorough understanding of interconnected managed care operations
• Demonstrated ability to develop workflows, policies, procedures.
• Demonstrated ability to identify opportunities for improvement & implement solutions.
• Excellent written & verbal communication skills.
• Excellent analytical skills demonstrated by an ability to use actionable data to support decisionmaking, and to proactively identify opportunities.
• Highly collaborative, and demonstrating good judgment in seeking consensus & input from multiple stakeholders to drive decision-making.
• Ability to take initiative & think independently
• Demonstrate understanding & acceptance of the MetroPlus Mission, Vision, & Values
• Leadership
• Results-driven
• Business acumen
• Systems orientation
• Process improvement
• Data-driven decision-making
• Customer focus
• Written/oral communication
• Resourcefulness
• Ability to work effectively in a fast-paced & constantly evolving environment

calendar_today 19 hours ago

 
 

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The successful candidate can be located anywhere in the U.S.A.

This position will be a point person for the Medicaid Actuarial team’s involvement with Revenue Integrity, a crucial initiative for the Medicaid Business Unit.

This position’s responsibilities will include (but are not limited to):
 

• Tracking performance of revenue integrity initiatives and building out the financial business case for newly introduced initiatives.
• Partnering with Medicare informatics to apply a revenue methodology that best forecasts the projected ROI to create chase lists for intervention programs.
• Constructing a database to calculate “should be” Medicaid revenue, which will allow for member-level valuation & prioritization to maximize ROI of revenue integrity efforts.
• Coordinating with Finance teams for risk score and revenue related SAIs.
• Aggregating and assessing risk score and pricing timelines for all Medicaid markets for purposes of initiative prioritization.

#AetnaActuary

Required Qualifications
7+ years actuarial work experience.

Must be an ASA or FSA and a member of the American Academy of Actuaries able to sign state rate filings and other required actuarial certifications.

Good communication skills and problem solving skills are essential.

COVID Requirements
COVID-19 Vaccination Requirement
CVS Health requires its Colleagues in certain positions to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, pregnancy, or religious belief that prevents them from being vaccinated.
 

• If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 30 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 60 days of your employment. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.

 
 

• If you are unable to be fully vaccinated due to disability, medical condition, pregnancy, or religious belief, you will be required to apply for a reasonable accommodation within the first 30 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. If your request for an accommodation is not approved, then your employment may be terminated.

Preferred Qualifications
Experience in Medicaid, prior work on risk adjustment, and experience with project management is preferred but not required.

Education
A Bachelor’s degree is required.

Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

 
 

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Diana Vargas

Independent Recruiter

• OVERVIEW

RESPONSIBILITIES
Contacts and assists VNSNY CHOICE members with Medicaid applications and recertification. Enters and updates member demographic information into the Recertification Tracking Tool. Identifies and investigates problematic recertification cases and presents for resolution. Works under general supervision. Education: Associate’s Degree in health, human services, other related discipline or equivalent work experience required. Experience: Minimum two years experience in health care, insurance, or social services processing bills and Medicaid applications required. Effective oral, written, verbal communication and customer service skills required. Personal Computer skills including Microsoft Word and Excel required. Analytical skills, including compilation and analysis of data, report creation and recommendations based on findings preferred.

QUALIFICATIONS

 
 

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Position Description


Mathematica applies expertise at the intersection of data, methods, policy, and practice to improve well-being around the world. We collaborate closely with public- and private-sector partners to translate big questions into deep insights that improve programs, refine strategies, and enhance understanding using data science and analytics. Our work yields actionable information to guide decisions in wide-ranging policy areas, from health, education, early childhood, and family support to nutrition, employment, disability, and international development. Mathematica offers our employees competitive salaries, and a comprehensive benefits package, as well as the advantages of being 100 percent employee owned. As an employee stock owner, you will experience financial benefits of ESOP holdings that have increased in tandem with the company’s growth and financial strength. You will also be part of an independent, employee-owned firm that is able to define and further our mission, enhance our quality and accountability, and steadily grow our financial strength. Learn more about our benefits here: https://www.mathematica.org/career-opportunities/benefits-at-a-glance.


Mathematica is searching for analysts with experience in Medicaid policy and programs at either the state or federal level. In particular, we are looking for individuals who can support current and emerging work across any number of areas related to monitoring and improving Medicaid programs such as: Medicaid managed care programs, value-based purchasing and alternative payment models, long-term services and supports, measures of delivery and quality of services for beneficiaries, data analytics, and outcomes of innovative programs and policies. Additionally, Medicaid analysts will work on or support project management, change management, and business development. Medicaid analysts work on a variety of projects spanning policy and programmatic areas. These projects range from data analytics to program evaluation and implementation support. Candidates do not need to have experience in all of these areas but should have substantial experience in at least one of them.


Across All Projects, Medicaid Analysts Are Expected To


Medicaid analysts will likely be connected to 2-3 projects at a time, with many projects requiring team leadership and direct-client contact.

• Lead or participate actively and thoughtfully in multidisciplinary teams to implement and monitor policy and programs, drawing on your past experience with Medicaid programs
• Apply rigorous analytic thinking to the collection and interpretation of quantitative and/or qualitative data, including analysis of Medicaid administrative data, managed care data, and site visits or telephone interviews with state and federal officials, health plan representatives, and providers
• Bring creative ideas to the development of proposals for new projects
• Provide the direction and organization needed to help keep projects on time and on budget and facilitate communications across and between internal and external stakeholders
• Contribute to the growth, expertise, and institutional knowledge of staff working in the Medicaid area
  
  

Specific Project Or New Business Development Activities May Include

• Conducting research projects on topics related to state and federal Medicaid policy
• Providing technical assistance to federal and state Medicaid stakeholders
• Assisting with quantitative analyses using Medicaid enrollment, claims/encounter, financial and program data to support program monitoring, improvement, or evaluation
• Developing technical specifications, user manuals, and other documentation to support the implementation of reporting systems and analytic tools
• Authoring client memos, technical assistance tools, issue briefs, chapters of analytic reports, and webinar presentations
  
  

Qualifications


Position Requirements:

• Master’s degree or equivalent in data analytics, public policy, economics, statistics, public health, behavioral or social sciences, or a related field, and at least 3 years of experience working in health policy or health research, with a substantial portion of that time focused on some aspect of the Medicaid program at the state or federal level; or a bachelor’s degree and at least 7 years of state or federal Medicaid experience.
• Strong foundation in quantitative and/or qualitative methods and a broad understanding of Medicaid program and policy issues
• Excellent written and oral communication skills, including an ability to write clear and concise policy and/or technical memos and documents for diverse stakeholder audiences including program administrators and policymakers
• Demonstrated ability to lead tasks or deliverables and coordinate the work of multidisciplinary teams
• Strong organizational skills and high level of attention to detail; flexibility to manage multiple priorities, sometimes simultaneously, under deadlines
  
  

To apply, please submit a cover letter, resume, transcripts (unofficial are acceptable), and contact information for for three references. Please also provide a writing sample that demonstrates policy analysis or program operation and monitoring skills, and reflects independent analysis and writing, such as a white paper or decision memo. You will also be asked to provide your desired salary range during the application process.

Various federal agencies with whom we contract require that staff successfully undergo a background investigation or security clearance as a condition of working on a project. If you are assigned to such a project, you will be required to obtain the requisite security clearance.

Available Locations: Princeton, NJ; Washington, DC; Cambridge, MA; Woodlawn, MD; Ann Arbor, MI; Oakland, CA; Chicago, IL; Remote

This position offers an anticipated annual base salary range of $63,000 – $95,000. This position may be eligible for a discretionary bonus based on individual and company performance.

Mathematica has implemented a mandatory COVID-19 vaccine policy for all employees working in any of our office locations. Unless a position is office-based, employees are currently being provided the flexibility to work remotely. Those choosing to work in an office or who prefer a hybrid work arrangement will be required to certify that they have received a COVID vaccine.

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Description

The Medicaid Lead, Technology Solutions builds strategic partnerships and manages relationships between IT and the aligned business group(s). The Lead facilitates guidance to business partners on information technology (IT) solutions, stays current on and leverages industry trends, and challenges business and IT to drive for best outcomes by leveraging the best technology solutions. This is achieved by having a clear understanding of business, its strategic direction, and targeted outcomes along with technology trends both internal and external to the organization. The role serves as the Single Point of Contact representing assigned business area(s) to the IT organization and representing Humana IT with internal business partners along with State and Federal regulators. The Lead ensures RFP responses are accurate and reflect the true and competitive capabilities Humana brings to the table, ensures internal SLAs are in place to support contracts and technology is configured to operate within contractual obligations. The Lead drives solutions at an organizational level to provide maximum value and align to the overarching IT strategy. They measure value to demonstrate and promote the value of IT to their respective areas and the organization as a whole.

Responsibilities

• Builds and maintains relationships with regulators and business leaders to understand the business strategy and needs and to advocate technology solutions to deliver results.
• Acts as a trusted conduit – the voice of the customer to IT and the voice of IT to the customer, ensuring the objectives of both are met.
• Stays current on relevant technologies leading efforts to match business needs with best technology solutions.
• Ensures Technology investment roadmaps stay relevant and accurately reflect the investment plan and timing for assigned business areas.
• Owns end to end accountability for the ongoing quality control development and delivery of IT products and services for each assigned business area. Accountable for program execution and delivery in line with initiative objectives, benefits, and success criteria. Develops, shares, and leverages best practices across IT
• Works with the business to define, prioritize, and manage projects that align with the business and IT strategy, for annual strategic plan
• Leads teams to gathers business requirements and clarify scope during initial discovery by conducting meetings/interviews, and facilitating large group/cross-functional sessions with partners
• Effectively influences key stakeholders, team members, and peers outside of direct control of this role, to deliver optimal solutions in line with the best interests and expectations of the business partner.
• Conducts executive level briefings presentations and solution recommendations

Required Qualifications

• Bachelor’s degree
• Solid understanding of operations, technology, communications and processes
• Possess 10+ years of progressive experience leading continuous improvement efforts, evaluating existing systems and implementing process improvements.
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• Master’s degree

Scheduled Weekly Hours

40

 
 

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We enjoy the important work we do every day on behalf of our members.

Job Summary

Under the administrative oversight of the Director, Pharmacy Operations, the Manager of Pharmacy Operations is responsible for the oversight, development, implementation, and maintenance of Point32Health (P32H) systems, as well as policies and procedures related to pharmacy operations. Responsibilities also include oversight of the Pharmacy Program Specialists and Coordinators responsible for supporting the enterprise call centers. This individual serves as the primary liaison to operational counterparts at the pharmacy benefit management (PBM) vendors to ensure accuracy and execution of pharmacy-related initiatives, programs, and benefit designs developed and implemented by the Pharmacy Department for Commercial, and Medicaid. This individual collaborates with key stakeholders across P32H to develop and support administrative and medical cost savings opportunities. This individual manages the work of the Pharmacy Operations Team to ensure that business results are successfully achieved. This individual interprets and complies with regulatory, compliance, and accreditation requirements for pharmacy operations and programs. As a Manager in the Pharmacy Department, this individual is a strong leader who engenders confidence among internal and external constituents.

Job Description

Pharmacy Benefit Manager (PBM) oversight and performance

• Define, implement, and continuously monitor the performance of pharmacy operations to meet the needs of members, providers, and key stakeholders for Commercial, QHP, and Medicaid
• Manage PBM operational performance, process improvements, and service issue resolution
• Ensure metrics and service standards are met to optimize customer experience
• Ensure PBM performance guarantees are met
• Recommend enhancements and refinements as needed to mitigate compliance risks
• Serve as primary liaison to PBM operations counterparts, providing oversight with current and prospective process automation and services
• Develop and implement standard operating procedures, holding PBM accountable for all operational functions in accordance with contractual agreement

Performance Management

• Develop, monitor, and maintain key performance indicators including, but not limited to: operational effectiveness, quality assurance/regulatory compliance, and departmental service level agreements
• Oversee the ongoing evaluation of current operational strategy and programs, directing improvements and process reengineering to ensure customer satisfaction and operational efficiency and effectiveness
• Prioritize the department’s work (programs, services, policies, operations)
• Develop resource plans for planned and unplanned work related to changes in the business environment, resource availability, etc.
• Manage maintenance of business and day-to-day issues. Ensure appropriate testing is completed. Analyze root causes and identify solutions of issues. Establish actionable next steps and project accurate completion dates.
• Monitor progress and team productivity, report overall status/measures of success, and identify issues and risks
• Collaborate with other departments within Pharmacy Services (e.g., Clinical Pharmacy, Utilization Management, Reporting, Contracting) to develop and implement annual requirements and cost-savings initiatives as well as track results
• Collaborate with departments outside of Pharmacy such as:Member and Provider Services; Enrollment, Premium Billing, Plan Benefits; Business Implementation; Sales, Marketing & Product Strategy; and Compliance

Annual plan benefit changes

• Scope, plan, and implement formulary and benefits changes which may include:changes driven by Product Strategy ; regulatory/compliance changes (e.g., state mandates, federal mandates); custom requests from employer groups
• Assess impact of proposed changes on members
• Oversee communications to members and providers
• Ensure pharmacy operations goals are appropriately aligned with P32H business priorities

Process improvement

• Proactively identify and prioritize areas for process improvement to achieve operational excellence
• Scope, plan, and implement process improvements, including c hange management and influencing stakeholders

Strategic initiatives

• Serve as key member of pharmacy management team, providing input to future pharmacy management strategy and strategic operating priorities
• Participate in and chair task forces or committees concerning pharmacy initiatives
• Ensure that pharmacy operations goals are appropriately aligned with THP business priorities
• Scope, plan, and execute strategic initiative projects

Requirements

• 7-10 years of progressive business experience in health care and/or managed care. Experience in health care service delivery, customer relations, and regulatory/compliance. Possess a fundamental knowledge of health care delivery systems, managed care. Experienced with large-scale project implementation and project management is desired
• 7-10 years of management experience supervising high-level professionals required, with demonstrated success in program development and execution
• Experience with healthcare operations, pharmacy benefits, formulary administration, and data analysis
• Must be able to work cooperatively as a team member with varying levels of staff throughout the organization. Must ensure compliance with confidential data and adherence to corporate compliance policy
• Strong planning, problem solving, analytic and change management skills. Ability to prioritize and manage competing issues and to effectively lead in a matrix environment.
• Strong presentation skills as well as highly-developed verbal and written communication skills.
• Excellent quantitative skills and attention to detail; strong analytic background preferred
• Excellent leadership ability to guide and inspire others, encourage high standards, and exemplify those standards. Requires strong skills at developing teamwork involving a multidisciplinary approach with staff and numerous departments throughout the company
• Requires a high degree of initiative, proactivity, and excellent judgment and decision-making ability. Ability to handle politically-sensitive situations and interact with a wide range of professionals. Requires the ability to work effectively in an extremely complex and often politically-charged environment, working with numerous interdepartmental contacts to problem solve and resolve complex provider issues
• Strong oral and written communication skills, working effectively with internal/external stakeholders including regulatory agencies.
• Requires excellent analytical skills necessary to formulate operational methodologies and analyze data. Must be adaptable to change and work in ambiguous situations while maintaining demeanor and performance under stress. Must possess the ability to critically assess new programs and policies and their impact on quality of operations. Requires a strong presence that will engender confidence among internal and external constituents.

What we build together changes our customer’s health for the better. We are looking for talented and innovative people to join our team. Come join us!

Clipped from: https://www.glassdoor.com/job-listing/manager-pharmacy-operations-commercial-medicaid-tufts-health-plan-JV_IC1154705_KO0,47_KE48,65.htm?jl=4168892051&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic&__cf_chl_jschl_tk__=pmd_51PaHkM7JBABYmKlt0dH3lb6KObgVBMpEVK2Av4BlCw-1632315718-0-gqNtZGzNAxCjcnBszQtR

 
 

 
 

 
 

Steward Health Care Network (SHCN) takes pride in its community-based care model, which drives value-added tools and services to our communities, patients, physicians, and hospitals across the continuum of care. In addition, Steward Health Care Network promotes care coordination and collaboration within the network in order to provide high-quality, efficient care to patients. With Steward in the community, all residents can be sure that there is a world-class doctor close to where they live.

The network is also responsible for the implementation and execution of our managed care contracts, medical management services, quality improvement programs, data analysis, and information services.

Position Purpose: Under the direction of the National Senior Director for Government Quality Programs, the Manager, Medicaid ACO Performance Programs oversees all aspects of performance initiatives, vendor management, and project planning for the Medicaid ACO. This role will lead key business initiatives aimed at ensuring operational efficiencies, meeting budgeted and contractual performance targets, and coordinating between cross functional business partners (e.g., Care Management, Pharmacy and Medicaid business unit) to drive quality performance outcomes for the Medicaid ACO. The role will assume a variety of tasks including, but not limited to, developing, and executing project and implementation plans, reporting on progress towards key business objectives, continuous QI/PI research and reporting, and vendor management.

• Develops and maintains Performance Programs strategic plan for the Medicaid ACO, ensuring that strategies are made with consideration of quality improvement, utilization management, care retention, and are developed using internal performance data, industry standards, and published literature
• Responsible for planning, coordinating, implementing, and overseeing strategies and tactics to support Performance Operations team with the goal of improving quality and financial performance. Provides project management support to QM, which may include creating and monitoring tracking mechanisms and monitoring improvement initiatives
• Oversees implementation and management of Performance Operations vendors and associated contracts for the Medicaid ACO. Ensures compliance of vendor obligations and optimizes use of vendor services and capabilities by Performance Operations team members
• Develops and maintains Performance Programs dashboard to identify opportunities for improvement, growth, and continued success, using competitive intelligence and industry research as applicable. Using data, evidence-based techniques, and business (contractual) priorities, identify top opportunities to improve performance measure rates and communicate these in a clear and timely fashion to leadership
• Creates plans, systems, and methods to support integration of new opportunities into the department’s workflow
• Oversees Medicaid ACO quality measurement, reporting and audits, including HEDIS, CAHPS, and custom state measures. Through data and analysis, evaluates impact of performance programs, and uses results to identify improvement and enhancement opportunities
• Project manages all aspects of collection of hybrid performance measure data and submission of this data to regulatory bodies in an accurate, complete, and timely fashion. Identify and implement opportunities to collect this data year round
• Manages quality improvement audit cycle, including project plans, training curriculum, and quality control of auditor’s work

Education / Experience / Other Requirements

Education:

• Bachelor’s degree required
• Master’s Degree preferred

Years of Experience:

• Four (4) + years of experience in health care quality focused roles that included medical record audits and/or performance metric i.e., HEDIS, Stars, or similar
• Significant experience in quality measurement, HEDIS, interpretation of claims data, medical record review

Specialized Knowledge:

• Strong computer skills, i.e., using various software, including intermediate Excel skills (sort, filter, reformat data, etc.)
• Strong analytic skills/ability to translate complicated data into useable information, including analysis of practice variation
• Successful experience managing complex projects beginning to end with accountability for outcomes, demonstrated organizational and project management skills to manage complex projects through effective planning, tracking, and resource allocation to meet business objectives and timelines
• Strong leadership and management skills; self-directed Ability to generate creative solutions

Steward Health Care is an Equal Employment Opportunity (EEO) employer. Steward Health Care does not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.

 
 

Clipped from: https://jobs.steward.org/manager-medicaid-aco-performance-programs/job/17537750?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic