Vice President Health Plan Operations PCHP

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion.

Primary Purpose
Responsible for leading and managing Parkland Community Health Plan’s (PCHP) operations consistent with strategic goals. Accountable for all lines of business and future lines of business into Medicaid, Affordable Care Act (ACA), Employee Insurance, and/or Medicare/Medicare Advantage. Provides leadership and directs the operations for Program Integrity, Special Investigations Unit (SIU), Benefits/Pricing/Configuration, Vendor Management/Oversight, Encounters, Reimbursement Methodology as well as Payment Appeals/Disputes and Claims.

Minimum Specifications
 

Education

• Bachelor’s degree in business administration or related discipline required.
• Master’s degree in business administration preferred.
   

Experience

• Five (5) years of operational leadership experience in a health plan required.
• Three (3) years of experience with Texas Medicaid, Medicaid and/or a Medicaid managed care organization required.
   

Equivalent Education and/or Experience

• Eight (8) years of leadership experience in Medicaid may be considered in lieu of a bachelor’s degree.
• Certification/Registration/Licensure
• Project Management certification or Six Sigma certification preferred.
• Certified Professional Coder or equivalent certification preferred.
   

Skills or Special Abilities

• Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines and with a variety of constituents as well as the ability to articulate complex information in understandable terms.
• Demonstrated ability to coach and influence for results.
• Excellent people skills with the ability to establish and maintain effective working relationships with diverse groups across and beyond the organization.
• Strategic thinking and long-range planning skills with the ability to lead major organizational initiatives, accomplish results, and achieve measurable outcomes or goals.
• Ability to work in challenging situations involving competing interests, and high level-interdisciplinary groups.
• Strong time management skills with the ability to manage multiple demands and respond to rapidly changing priorities.
• Ability to facilitate holistic thinking and problem solving.
• Knowledge of Texas Medicaid (STAR, STAR Kids/CHIP) program, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual.
• Sound business acumen.
• Proficient Microsoft Office and computer skills.
   

Responsibilities

Strategy

• Formulates business strategies and operational plans for optimal performance. Assembles and manages a successful, collaborative team of people to achieve these goals.
• Informs and advises the CEO regarding state’s current trends, problems and activities to facilitate both short- and long-range strategic plans to improve operational performance and enhance growth.
• Designs, coordinates and completes operational improvement projects across various functions in PCHP.
• Oversee business operations, implementations (changes, new products) and complex initiatives.

Health Plan Operations

• As a member of the senior leadership team, accountable for achieving PCHPs financial, quality and service goals.
• Oversees the day-to-day business activities of the contract and manages daily operations.
• Serves as the primary point of contact for all health plan operational issues.
• Manages and administers multiple health plan functions and general business operations working collaboratively with health services, medical management, quality, marketing and provider network/services.
• Provides subject matter expertise in project management, project scope definition, risk identification, project methodology, resource allocation and other areas accountable for operational results.
• Direct and develop operational work processes and systems with direct oversight for multiple departments.
• Identify operational efficiencies, meet regulatory and stakeholder expectations, and develop a best practice approach for operations.
• Assess organizational strengths and weaknesses to recommend an enhanced operating model.
• Develop and implement an operational excellence model to ensure cost effective programs are developed and maintained. Identify improvement opportunities and oversee successful implementation of those changes throughout vendor services, external parties and internal / shared services.
• Quickly escalates performance issues to PCHP CEO or leadership along with clear action plans to mitigate.
• Ensures operational audit processes exists for all operational elements (internal and external) including member enrollment data, claims payment accuracy and timelines, benefit accuracy and timelines, encounter submissions accuracy and timelines, and member/provider hotline.

Regulatory

• Understand and manages the state requirements and relationship related to operations.
• Develop processes to maintain compliance with regulatory agencies and accrediting bodies. Ensures operations are carried out in compliance with these regulations.
• Works collaboratively with others to validate and sustain compliance with regulatory and accreditation standards.
• Conducts routine compliance audits identifying gaps and implementing remediation plans as necessary.
• Works collaboratively with leadership and/or PCHP Compliance to investigate and respond to matters of concern or alleged violations taking corrective action as necessary.
• Provides timely and accurate responses to requests for information from regulatory agencies and accrediting bodies.
• Proactively develops, tracks and reports operational compliance requirements, key performance targets and/or associated service level agreements.
• Provides consultative expertise or guidance to respond appropriately to changing laws or contract requirements.

Fiscal Management and Operating Budget

• Operationally responsible for the financial performance of assigned area(s).
• Promote activities to achieve operational efficiency.
• Responsible for achieving business unit financial targets and requirements based on service level, state, compliance, and contractual agreements.
• Manage the approved budget through frequent and regular monitoring. Implement written action plans to address variances adjusting strategies as necessary to meet budgetary targets.
• Consider operational outcomes and financial implications when making recommendations to implement new programs or modify current programs.
• Manage staffing levels within established targets.

Talent Management

• Recruit and retain diverse talent with a variety of backgrounds, skills, experiences, and viewpoints that reflect the communities we serve.
• Promote and support a culturally welcoming, inclusive, collaborative, and highly engaged work environment where everyone feels empowered to bring their full, authentic selves to work.
• Accountable for orientation, ongoing education and training, and competency verification for all employees.
• Ensure Human Resource metrics (i.e., retention, vacancy, engagement) meet established targets. Utilize workforce metrics to monitor, identify, and respond to workforce trends.
• Timely completion of employee performance appraisals.
• Conduct regular meetings, inform team of changes in policy or procedure, and provide information regarding overall strategy and direction of the health plan.
• Mentor, coach, and support direct reports with building teamwork, professional development, and education to achieve optimal performance and develop talent.
• Ensure employee engagement survey participation rates and results meet established targets.
• Mandatory requirements are completed timely by employees.
• Required licensure, certification, and/or registry are current and in good standing for all employees.
• Employee performance is monitored and managed. Consult with the Office of Talent Management as appropriate regarding employee performance concerns and disciplinary action.

  
Professional Accountability

• Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values.
• Adheres to organizational policies, procedures, and guidelines.
• Completes assigned training, self-appraisal, and annual health requirements timely.
• Adheres to hybrid work schedule requirements.
• Attends required meetings and town halls.
• Recognizes and communicate ethical and legal concerns through the established channels of communication.
• Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information.
• Maintains confidentiality at all times.
• Performs other work as requested that is reasonably related to the employee’s position, qualifications, and competencies.

Job Accountabilities
 

1. Identifies and analyzes the design of jobs, work processes, work flows, etc. for the area and implements appropriate changes to improve effectiveness, productivity, and efficiency that support the overall goals of the department and Parkland.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as needed to ensure proper understanding.
4. Develops and monitors annual budgets that ensure the department has the necessary funds to carry out the goals and objectives that have been established for the department.
5. Develops, implements, monitors, and revises annual goals and objectives for the department that support the missions and objectives of Parkland.
6. Selects, trains, schedules, motivates, supervises, and evaluates employees making recommendations for disciplinary actions up to and including termination, to ensure maximum utilization of individual and group capabilities. Ensures that assigned employees receive opportunities to further their knowledge.

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Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status. As part of our commitment to our patients and employees’ wellness, Parkland Health is a tobacco and smoke-free campus.