Reporting to the Executive Dir for the Continuum, w/secondary accountability to Area Mrgs, this position is responsible for the development, planning, Mgmt, & the integration & delivery of KFH/HP operational system processes & standards of practice, in alignment w/the organization's mission, strategic business plan, & related performance improvement expectations.
- In collaboration w/Reg-l Continuum Administrators achieves/exceeds performance expectations for all areas of continuing care operations, including Home Health/Hospice, SNF, DME, Ambulance, Claims&Referrals, & Eldercare, Palliative Care, ESRD, Psych, Social Srvs, Case Mgmt, Continuing Care UM, Revenue outside the hospital, Shared Continuing Care Srvs, H/HP Benefit Application, Contracts.
- Has joint responsibility for Home Health & Hospice, DME, Ambulance, Utilization Mgmt, Social Srvs, & Contracts.
- In collaboration w/local & Reg-l Leadership defines & communicates strategic objectives & scope. Articulates issues or problems from a broader organizational/mission perspective.
- Creates the structure & processes to develop, implement & evaluate programs, policies & standards for continuing care srvs to ensure coordinated plans of treatment, delivery systems that meet member needs, & cost effective utilization of necessary srvs.
- Ensures the integration of quality, srv & efficiency improvements into day-to-day operations.
- Establishes appropriate methods to define, categorize, & monitor claims & referred srvs. Provides oversight to the data & reporting systems used to track the performance of continuing care operations.
- Works collaboratively w/medical group & labor leadership to recommend srv delivery changes or internalization of srvs where appropriate.
- Works w/Reg-l continuing care leadership to establish appropriate case Mgmt programs to monitor & manage the care of members in non-KFH facilities.
- Ensures the successful operational implementation of HealthConnect continuing care functionality.
- Responsible for the efficient delivery of all continuing care srvs for KP members by overseeing the development, negotiation, & utilization of cost-effective, high quality contracts w/outside providers.
- Establishes joint contracting relationships across medical centers where appropriate. In collaboration w/HPRS, establishes policies, procedures & protocols for the reimbursement of claims submitted by KP members for outside srvs to maximize reimbursement revenue from other insurers (e.g., Medicare or Medi-Cal) w/consistent & appropriate interpretation & application of the health plan benefit.
- Manages the Health Plan function in ensuring implementation of new deductible plan products w/in the local areas.
- Monitors & assesses trends, external environment & internal practices; makes recommendations to develop/adjust strategy to meet the changing business & market conditions.
- Builds relationships w/local leadership & community partners to develop & meet utilization targets & related quality goals in the continuum.
- Works w/KFH/HP, TPMG & labor leaders to target diseases/conditions such as Palliative Care, Behavioral Health, Elder Care that would benefit from a Reg-l multidisciplinary approach.
- Sponsors clinical pathway development, implementation & evaluation.
- Builds the case for change & articulates costs & risks for not making change. Champions new ways of meeting targets &/or goals. Explores critical issues not explicitly addressed by others. Anticipates & plans for future issues or problems.
- Recommends adjustments to operations to improve efficiency & to meet changing business needs.
- This job description is not all encompassing.
- Minimum ten (10) years of experience in clinical and managerial roles in a multi-faceted health care system and multi-service provider setting required.
- Bachelor's degree in health services or business administration, public health, nursing or related discipline required.
License, Certification, Registration
- Demonstrated success in meeting/exceeding performance expectations.
- Demonstrated expertise in project management, problem solving, verbal and written communication and collaborative working skills.
- Demonstrated ability to function collaboratively in a multi-entity partnership environment.
- Able to lead and manage through influence and change.
- Able to manage various stakeholder interests and demonstrated skills in facilitation, problem solving, decision making, persuasion and team-orientation.
- Thorough knowledge of quality assurance, resource management, health plan regulatory and licensing processes including federal and state laws and regulations such as: Knox-Keene Act, Federal HMO Act, Public Employees Medical and Hospital Act, The Joint
Commission, and all applicable Medicare and Medi-Cal regulations.
- Must be able to work in a Labor/Management Partnership environment.
- Master's degree in one of the aforementioned fields preferred.
- Current valid California RN license strongly preferred.
Job Number: 745414