SWHRCIN VP Medicar Adv Ops CNC SWHRCIN at Southwestern Health Resources CIN in Pittston, Pennsylvania

Job Description:

Southwestern Health Resources, which blends the strengths of University of Texas Southwestern Medical Center and Texas Health Resources, includes a clinically integrated network of 29 hospital locations and more than 5,000 providers, committed to being the national leader in population health.

SWHR is transforming population health by harnessing machine learning platforms and developing leading predictive analytics that set national standards. With more than 650 points of access to care, this provides for higher value and allows patients to access services across a full continuum of medical needs. The network serves people across 17 counties in North Texas. In total, Southwestern Health coordinates care for more than 700,000 patients, aligned with commercial health care plans and Medicare programs. SWHR operates the nation's highest rated Next Generation Accountable Care Organization.

Reporting to the Senior Executive Officer, the VP Medicare Advantage Operations will work strategically with executive leadership to ensure all MA operational functions are consistently aligned and compliant with key organizational value and mission-critical initiatives.

This position is responsible for leading the organization's Medicare Advantage health plan including oversight of call center, enrollment, appeals & grievances, claims (including TPA oversight), business solutions, office management, vendor implementations, regulatory and operational compliance. This position requires a highly motivated leader with a keen understanding of the "big picture" and how it relates to directing cross departmental functions with attention to key details. The applicant for this position must have maintain an advanced understanding of the laws and regulations specific to the Medicare Advantage with significant expertise in claims adjudication processes.

Responsibilities and Duties:

• Develops operational staffing and organizational structure based on business needs • Leads and manages relations with Third Party Administrator who processes claims on behalf of the health plan. • Leads Medicare enrollment and eligibility processes and provide leadership on resolution of new member issues. • Leads the Appeals and Grievance function, ensuring compliance with all state and federal regulations. • Leads the development, implementation and ongoing measurement of programs in Member Services to meet the performance standards of CMS and the health plan. • Leads operational performance of each functional area towards measurable goals and objectives. • Responsible for office management including operational functions of office, front office services and facility related issues as they pertain to office management. • Leads annual Enrollment Period (AEP) to increase plan membership year-over-year • Leads the consistent evaluation and delivery of existing operational processes for performance and improvements. • Leads relationship with health plan vendors and delegates, partnering collaboratively for continued successful performance, quality, retention and engagement across all product implementation or de-implementation as necessary. • Leads the development and implementation of customer service strategies to ensure effective two-way feedback while motivating a high-performance productive environment. • Provide leadership and support in identifying and offering solutions to problems of reported trends in ensuring employees and departments are meeting and/or exceeding weekly, monthly and yearly goals. • Continuously evaluates operational efficiencies and process improvement for each functional department. • Maintains up to date product and service knowledge to support internal and external vendors, customers and employees • Provides feedback and recommendations to leadership on business operations, performance, progress, strategies and issues. • Responsible for health plan operational compliance delivery with regulatory and contractual requirements. • Responsible for delivering on all service, retention, and employee measures for operational departments.

Professional Experience/Qualifications:

Individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individual with disabilities to perform the essential functions. This role requires the ability to solve problems, think outside-the-box, and be resourceful; must be result-oriented, a quick learner and self-starter. Comfortable working in complex and matrix organizations. The requirements listed below are representative of the knowledge, skill, and/or ability required to build SWHR's culture for action.

• Bachelor's degree from accredited college in Health Care Administration, Business or related field required. • Master's Degree from accredited college in Health Care Administration, Business or related field preferred. • 8 years' related experience in Medicare advantage operations experience with an emphasis on claims management, membership growth, leading high-performance teams, project management and system/program implementations required.