|Job Description: ||
About WellCare: WellCare Health Plans, Inc. provides managed care services targeted to government-sponsored health care programs, focusing on Medicaid and Medicare. Headquartered in Tampa, Fla., WellCare offers a variety of health plans for families, children, and the aged, blind and disabled, as well as prescription drug plans. The company serves approximately 2.7 million members nationwide as of Dec. 31, 2012. The company employs more than 4,500 nationwide. For more information about WellCare, please visit the company's website at www.wellcare.com. A Fortune 500 company traded on the New York Stock Exchange (symbol: WCG). |
EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, sex, age forty (40) and over, disability, veteran status, or national origin.
The VP, Clinical Services directs the plan’s health services function which may include preauthorization, concurrent review, complex case management, quality improvement, credentialing, health and wellness, and disease management. The incumbent has oversight of the overall coordination, implementation and monitoring of activities to yield quality driven, compliant, efficient and cost-effective results.
Position Location: Tampa, FL 33634
Reports to: SVP & Chief Medical Officer
Department: Health Services
- Oversees staff performance to assure utilization management standards are continually maintained and medical costs meet established parameters. Provides support and direction for department supervisory personnel as well as staff members.
- Coordinates the development, implementation and application of policies and procedures for utilization management, quality improvement, disease management and credentialing. Interacts with Corporate, and other health plan Medical Directors and Health Services management as needed.
- Serves as a resource both to department staff and those outside the department for information and consultation on issues relating to clinical services and medical affairs, including such issues as case management, disease management programs, and utilization management activity.
- Advises committees on current standards and requirements for their respective programs.
- Maintains a working knowledge of legislative changes that may potentially affect utilization trends, practices, and standards. Ensures that compliance and regulatory standards are met with regard to department policies and procedures.
- Ensures adherence for accreditation (NCQA, URAC, other) activities within the Enterprise.
- Researches and evaluates medical care delivery alternatives to ensure high quality, cost effective services. Determines cost containment measures that complement quality care.
- Ensures that pertinent, comprehensive, and accurate statistical information related to Plan activities is available and monitored.
- Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including employment, termination, performance reviews, salary reviews, and disciplinary actions.
- Cultivates interdepartmental communication and cooperation to maximize service to members and providers and to assure a coordinated and comprehensive approach to problem solving and utilization management.
- Performs other duties as required.
Education: A Bachelor's Degree in nursing required; a Master's Degree in nursing or healthcare administration preferred.
- 10 years of experience in a health insurance environment with an emphasis in managed care programs required.
- 7 years of management experience preferably in a managed care environment required.
- Thorough knowledge of utilization review practices and standards for managed care delivery programs, ICD-9-CM and CPT coding, discharge planning, quality improvement and credentialing.
- Knowledge of healthcare delivery.
- Knowledge of information systems programs related to managed care.
- R.N. with active licensure required
- Certified Case Manager preferred
- Ability to work within tight timeframes and meet strict deadlines
- Ability to create, review and interpret treatment plans
- Demonstrated negotiation skills
- Demonstrated time management and priority setting skills
- Demonstrated leadership skills
- Demonstrated written communication skills
- Demonstrated interpersonal/verbal communication skills
- Ability to effectively present information and respond to questions from peers and management
- Ability to implement process improvements
- Ability to work in a fast paced environment with changing priorities
- Ability to work in a matrixed environment
- Ability to effectively present information and respond to questions from families, members, and providers
- Ability to work as part of a team
- Demonstrated organizational skills
- Intermediate proficiency in Microsoft Outlook, Word, Excel, PowerPoint, and Project
- Intermediate proficiency in a Healthcare Management System