Opportunities at WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff and non-patient-facing roles, you can make a difference with us as you discover the meaning behind *Caring. Connecting. Growing together.  *

The Vice President of Care & Affordability Operations is responsible for successfully executing all Medical Management activities for their region. The Vice President is responsible for planning, organizing, and directing the administration of all Medical Management Programs such as Care Management (Utilization Management, Case Management, Disease Management), and Advance Care Management (Palliative Care) programs. The VP provides oversight to ensure activities are appropriately integrated into strategic direction and operations, as well as the mission and values of the company.

The VP maintains organizational structure and oversight of procedures, employment, training, and supervision of all Medical Management staff. The VP directs long-term planning and communication regarding Medical Management issues with network physicians; and acts as a resource to all internal and external customers. The Vice President coordinates duties with appropriate personnel to meet operational program needs, ensures compliance with state and federal health plan requirements, Medicare guidelines, NCQA and URAC standards. The Vice President implements policy and procedures to maintain corporate and service initiatives. The Vice President integrates current clinical practice guidelines for care management services. The Vice President is also responsible for cultivating new leadership for the department.

Primary Responsibilities:

• Leadership: Directs the overall activities of staff in the department. Serves as source of expert knowledge for all activities undertaken in the department. Establishes priorities for staff and facilitates bilateral communication between line staff and department management. Serves as contact for communication and problem resolution for issues raised by managers from other departments. Presents professional appearance and demeanor at all times.

• Committee Support: Actively participates in Medical Management and Quality Committee. Accountable for disseminating information to the Committee regarding market activities. This involves annual evaluation of the program with recommendations for revision as indicated. Actively participates in committees such as Medical Finance, market monthly strategic meetings, and other care management related committees.

• Compliance: Oversees and ensures that Care Management and Quality staff adhere to all regulations, contractual agreements, and applicable NCQA/URAC and other applicable accreditation standards. In addition, ensures adherence to other UM/CM/DM delegated agreement standards and expectations for all contracted health plans. Ensures internal audits are conducted, reviews results, formulates and implements appropriate action plans to correct any areas of noncompliance. Collaborates with Training to provide in-services on compliance to better prepare the department for audits. Makes recommendations for revisions and updates in structure and procedure to the enterprise Sr. VP and MM/Quality Committee for improvements to Medical Management functions and implements any new procedures.

• Customer Service: Implements Medical Management programs in a manner that provides a high level of service to patients and providers and is no more burdensome than necessary to manage the care effectively and efficiently.

• Staff: Manages staffing ratios of all personnel, the assignment of duties, the supervision of the effectiveness of the Medical Management programs related to staff, within the structure of the budget for the department. Ensures staff have access to necessary training relevant to their duties to maximize operational efficiency using all resources available. Evaluates performance of staff on a timely basis, providing feedback in the most constructive manner. Implements Plan or Improvement for deficiencies in meeting Medical Management performance goals. Works with directors and managers to develop processes to meet the guidelines for employee ratio to work volume.

• Team Building: Encourages Medical Management staff to develop skills and knowledge for personal growth and promotion of position. Fosters leadership skills for supervisor positions to ensure most qualified staff performs management of processes. Promotes appropriateness in the utilization of staff by being flexible and assisting others when a staffing problem occurs. Identifies and helps develop future leadership candidates.

• Education: Maintains a personal level of professionalism through attendance at required meetings and evaluates problematic issues using all resources for resolution. Cultivates relationships with medical groups and primary care physicians as well as all departments within the enterprise for customer development and knowledge sharing. Keep abreast of all new or revised policies and procedures when posted or distributed and is accountable for distributing information to all committees. Conduct one on one session when indicated to promote staff development of knowledge and resource information.

• Planning and Future Development: Under the direction of the MM Committee, is responsible for maintaining a continuum in policy meeting national standards and health plan guidelines guaranteeing the effectiveness and success of the UM Program. Under the direction of Physician Advisory Committee, is responsible for development and management of clinical guidelines.

• Customer Communication: Promotes communication to customers by informing them of updates and revision in MM policies using training or orientation opportunities, newsletters, or other available resources such as forum presentations. Takes ownership of the total work process and provides constructive information to minimize problems and increase customer satisfaction.

• Confidentiality: Respects customer and organizational confidentiality. Also respects the confidentiality of contractual arrangements and personnel issues of Medical Management staff.

• Resource Management: Designs and implements programs to eliminate inappropriate use of medical resources. Uses all supplies and services in a resourceful and responsible manner.

• Budget Management: Responsible for planning the Medical Management SG&A and capital budget and all expenditures within the framework of the company budget. This responsibility includes the management of salaries, operating expenses, and Medical Management assets used for daily operations.

• Delegation Oversight: Collaborates with Leadership of Delegation Management to ensure compliance with delegated requirements. Monitors monthly, quarterly and annual reporting according to delegation agreement and ensures annual assessments are conducted as applicable according to the delegation agreement, URAC, NCQA and CMS standards.

• Reviews and analyzes all management operational metrics, outcomes and utilization statistics. Identifies trends and patterns requiring intervention and process improvement. Responsible for implementation of UM, CM, DM and Quality work plans and annual program evaluations.

• Other duties: Performs all other related duties as assigned.

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Active and unrestricted Registered Nurse license in any US state with the ability to obtain a Florida license within 12 months of starting employment

• 8+ years of management-level utilization management experience in managed care with health plans required, including 5+ years of experience at the Director level or above

• Experience in contract language, claims, utilization management guidelines and accreditation guidelines

Additionally, the Vice President must be able to perform each of the following essential duties satisfactorily. The requirements below are representative of necessary knowledge, skill and ability.

• Knowledge of federal and state laws and NCQA regulations relating to managed care, disease management, utilization management, discharge planning and complex care case management

• Knowledge of basic principles and practices of clinical nursing

• Knowledge of referral processes, claims, case management, and contracting and physician practices

• Knowledge of fiscal management and human resource management techniques

• Ability to effectively plan programs and evaluate accomplishments

• Ability to present facts/recommendations in oral and written form

• Ability to analyze facts and exercise sound judgment arriving at proper conclusions

• Ability to plan, supervise and review the work of professional and support staff

• Ability to apply policies and principles to solve everyday problems and deal with a variety of situations

• Ability to exercise initiative, problem-solving, decision-making

• Ability to establish and maintain effective working relationships with employees, managers, healthcare professionals, physicians and other members of senior administration and the general public

• Effective written and verbal communication skills

• Proficient with computer software programs, to include: word processing, spreadsheets graphics and databases

• Requires full range of body motion including handling and lifting patients as needed, manual and finger dexterity and hand-eye coordination

• Rarely must lift weight of up to 100 pounds

• Requires corrected vision and hearing to normal range and must be able to speak clearly

• Requires working under stressful conditions or working irregular hours

• In and/or out-of-town travel is required

Preferred Qualifications:

• 15+ years of experience in a managed care and/or disease/case/utilization management with ten or more years of management level experience

Physical & Mental Requirements:

• Ability to lift up to 10 pounds

• Ability to push or pull heavy objects using up to 25 pounds of force

• Ability to sit for extended periods of time

• Ability to stand for extended periods of time

• Ability to use fine motor skills to operate office equipment and/or machinery

• Ability to receive and comprehend instructions verbally and/or in writing

• Ability to use logical reasoning for simple and complex problem solving

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for this role is $122,100 to $234,700 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.