VP Continuum Services

Overview:

As we continue down the road of creating “One CommonSprit,” the PHSO is a major step forward in our ability to leverage our size and scale to provide services that will support value-based care performance, strengthen our networks, and help us keep pace with the evolving reimbursement landscape.

Local markets will increasingly be able to access high quality standardized tools and fill any capability gaps they may currently have.

As one of the nation’s largest providers in value-based care with 2.6 million attributed lives, we are uniquely positioned to make a high impact difference in this space. Through the PHSO, we will be able to further promote high-quality, affordable and evidence-based care for our patients across our communities.

The VP will engage internal and external stakeholders to promote an integrated care coordination model, supporting the mission and vision to enhance population health and value-based care on a national scale. Please note this is a remote role.

Responsibilities:

• Oversees and/or directs the development, implementation and standardization of PHMSO wide care continuum coordination, utilization management, social work services and out-of-network policies for delegated networks, procedures and programs in conjunction with related goals and objectives. Ensures compliance with federal and state regulations, as well as established organizational policies and procedures.
• Provides leadership oversight to the Managed Care - Director of Continuum Care Management (MC-CM) ensuring partnership with Managed Care Medical Directors. This includes ongoing program and strategy development which will improve managed care performance in partnership with delegated network partners.
• Provides leadership oversight to the Managed Care - Director of Utilization Management (UM) ensuring partnership with the Managed Care Medical Director of UM for the implementation and compliance to all delegated and non-delegated care coordination responsibilities throughout Managed Care, including compliance with all regulations for National Committee for Quality Assurance and other regulatory bodies supporting care coordination activities.
• Provides leadership oversight to the Population Health - Director of Continuum Care Coordination (PH-CCC) ensuring partnership with value hub leadership Continuum Care Coordination leadership. This includes ongoing program and strategy development which will improve performance under population health value based programs in partnership with CommonSpirit value hubs and respective networks.
• Provides leadership oversight to the Managed Care - Director of Utilization Management (UM) ensuring partnership with the Managed Care Medical Director of UM for the medical necessity reviews, denials management, and utilization management supporting all areas of the organization within the assigned region. This includes strategy development which will improve reimbursements and reduce denials as related to federal, state and commercial programs in partnership with delegated network partners.
• In partnership with the PHMSO Vice President for Quality, works to align Continuum Clinical Care Services work streams with priorities for PHSO population health and managed care quality programs.
• Establishes and oversees the development and implementation of continuum programs, short and long-range goals and objectives and determines the optimal progression to obtain these goals. Reviews analyses and reports of various activities to determine department progress toward stated goals and objectives.
• Maintains effective communication and a strong leadership presence with executive partners, senior leaders, internal and external customers to coordinate and adequately address patient and member care needs.
• Continuum Care Coordination models will support a patient-centered care delivery model across CommonSpirit population health value hub and managed care operations. Responsible for the ongoing development and implementation of standards, systems, policies, and procedures in alignment with organizational strategic initiatives and that is focused on the quadruple aim and applicable accreditations (ie. URAC, NCQA, et al).
• Utilization Management model is responsible for the day-to-day operations of the UM nursing teams including pre service utilization review, concurrent inpatient review and retro claim review. Oversight of utilization management auditing, both internal and external, for all PHMSO population health and managed care service areas as well as the development of UM work plans for submission to health plans as needed. Oversees operational efforts for bringing on new lines of business into the UM workflow.
• Out of Network (OON) model leads strategic improvement with OON team to improve care management coordination between hospitals, medical groups and IPAs throughout all PHMSO population health value hubs and managed care service areas. This includes the planning, managing, analysis and communication in regards to the entire model with executive leadership.

Qualifications:

Experience, Education, and Licensure:

• Minimum of ten (10) years of experience in healthcare managerial experience.
• Master’s Degree - Masters Degree in healthcare or business related field.
• Current Registered Nurse (RN), Social Worker (SW) or equivalent licensure preferred.

Benefits Include: Benefits include Medical, Dental, Vision, Paid Time Off, Holidays, Retirement Program, Disability Plans, Tuition Reimbursement, Adoption Assistance, Employee Assistance Program (EAP), Discount Programs, Life Insurance Plans, Worker Compensation, Dress for Your Day Policy, Voluntary Benefits.

Position is eligible for incentive pay based on company performance.

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