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Sr VP Health Services | Medical Management

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Open, CA
Job Type
Direct Hire
Dec 09, 2018
Job ID
Sr VP Health Services | Medical Management - CA


Advance your career AND make a difference!  Exceptional opportunity for someone who thrives on quantifiable results to drive improvement in quality, outcomes, and operational efficiency, enhancing care delivery and quality of life for the membership of this international, mission -driven MCO.    

                      GENEROUS relocation and compensation - AMAZING career potential

SVP will be a key part of the leadership team in the CA market, working collaboratively with internal and external stakeholders, including providers.  Coordinate medical management, vendor delegation oversight, provider performance and key accounts relations. Support the company’s strategic plan, establish the strategic vision and ensure policies and procedures are maintained.  This is a very analytic and measurement driven position with the expectation to improve operations by re-evaluating process, identifying and resolving gaps, driving continuous improvement.  

Direct and coordinate UM, DM, CM; provider performance and incentives; vendor delegation oversight; and network key accounts maintenance and relations. Responsible for the development, execution and monitoring of vendor performance metrics.

Review analyses of activities, costs, operations and forecast data to determine progress toward stated goals and objectives. Work with delegated vendors to achieve set targets supportive of Plans overall goals.

Monitor and assist vendors in successful completion of corrective action plans. Prepare delegated vendors for Plan’s NCQA accreditation.
Responsible for the execution and monitoring of provider incentive plans. Monitor provider performance and HBR. Meet with providers quarterly to review incentive performance and HBR; make recommendations on interventions leading to better incentive outcomes for participating providers.

Create and maintain collaborative partnerships with key accounts (large medical groups and hospital consortiums). Work to establish collaborative relationships by fostering excellent customer response and quick, appropriate problem resolution.

Serve as a member of management committees on special studies.

Administer and ensure compliance with NCQA and/or JACHO standards as determined for accreditation of the health plan.

Participate in, attend and plan/coordinate staff, departmental, committee, sub-committee, community, State and other activities, meetings and seminars.


- Minimum Bachelor’s degree in Nursing or related field.

- 10+ years of experience with health plan operations. 

-  Extremely clinically and operationally strong.

-  Must be able to turn data into actionable results. 

- Previous experience with QI practices and development of strategic initiatives to enhance plan’s performance.

- Familiarity of medical information systems, medical claims payment process, medical terminology and coding.

- Working knowledge of case management practices, managed care, and Medicaid programs.

-Working knowledge of NCQA accreditation process and standards.

- Previous leadership experience including hiring, training, assigning work and managing performance.

License/Certification: Registered Nurse Required (willing to obtain CA)- CCM preferred