Chief Health Services Officer

Stellenbeschreibung:

Provide strategic direction across HPSJ Health Services functions, consistent with contractual and regulatory requirements and organizational strategies
Oversee Utilization Management, Case Management, Behavioral Health and Social Work, Quality Management, Quality Improvement and Health Equity, Health Education, HEDIS and NCQA, and Grievance and Appeals functions
Supervise executive directors, directors, managers, and an executive assistant across Health Services
Oversee operational objectives, business plans, tactics, and care program implementation
Analyze care opportunities, issues, and trends; recommend and implement changes
Collaborate with the Chief Medical Officer on Quality Improvement and Quality Management Programs
Provide direction on medical claims review, grievances, appeals, and other Health Services issues
Ensure consistent application of medical criteria in utilization management decisions
Develop programs and educational opportunities for providers and members regarding Quality Improvement and Health Equity Transformation goals
Coordinate Health Services and organizational teams with a focus on member care
Lead health equity efforts to meet or exceed CMS, DHCS, DMHC, and NCQA requirements
Develop policies, procedures, targeted interventions, and metrics to improve health equity and reduce health disparities
Ensure required diversity, equity, and inclusion training for staff, subcontractors, and network providers
Co-chair the Quality Improvement and Health Equity Transformation Committee and oversee the Health Equity Annual Report
Represent HPSJ with county partners and participate in state and industry work groups including DHCS, DMHC, CHCF, NCQA, ACAP, and CAHP
Prepare and oversee internal and external audits, regulatory reviews, corrective action plans, and quality reports
Oversee quality concern trends and medical delivery system quality issues
Develop and manage department budgets
Oversee collection, storage, and retrieval of relevant data and information
Maintain required records, documents, policies, and procedures
Promote organizational values and a supportive workplace environment
Hire, develop, retain, coach, and mentor Health Services leaders and staff

Requirements

Legal and valid work authorization, Green Card, or U.S. citizenship; the Health Plan does not sponsor visas
Must reside in California
Bachelor’s degree in nursing from an accredited nursing school
At least six years in clinical operations in a healthcare setting
At least six years in progressively responsible leadership positions in a healthcare setting
Experience in an HMO or managed care setting
Experience in utilization management, case management, or behavioral health for government-sponsored programs
At least five years of experience developing and implementing Quality and Population Health Programs in a managed care setting in a senior leadership role
At least three years of experience developing and/or implementing healthcare diversity initiatives addressing health equity and health disparities
Certificate in Health Equity and Diversity, Health Disparities and Health Inequality, or another certification meeting California and/or federal requirements, or obtain within one year of hire
Valid driver’s license
Current unrestricted California RN license (if RN)
Expert knowledge and proficient skills in administering clinical operations protocols
Expert knowledge of Medi-Cal and Medicare regulatory requirements for utilization management, case management, and behavioral health
Knowledge and ability to identify, implement, monitor, and analyze relevant metrics models
In-depth knowledge of healthcare contract components and language
In-depth knowledge of audit, control, and monitoring processes
In-depth knowledge of medical management information systems and their interrelationships
In-depth knowledge of health equity and diversity principles, concepts, and best practices
Strong knowledge of medical policy benefits and exclusions
Strategic planning and business plan development skills
Very strong project management, facilitation, negotiation, conflict resolution, collaboration, interpersonal, communication, presentation, coaching, and counseling skills
Strong budget development and management skills
Customer service skills
Intermediate mathematics skills, including basic algebra
Intermediate skills in Word, Excel, and Outlook, including spreadsheets, formulas, tables, and graphs
Ability to speak and be understood in English
Ability to handle confidential information with discretion
Preferred: strong clinical skills; knowledge of California or San Joaquin County healthcare issues; Medi-Cal and/or Medicare knowledge; managed care knowledge; and diversity, equity, and inclusion research and best-practice knowledge
Preferred master’s degree in nursing, business, public health, or similar

Core Competencies

Demonstrates expertise in clinical operations, quality improvement, and health equity initiatives within managed care settings. Proven ability to lead diverse teams, develop strategic plans, and ensure compliance with regulatory requirements.