Chief Health Services Officer

Job Description

Job Description

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. 

At this time, the Health Plan does not sponsor visa. Candidates must have legal and valid work authorization, Green Card, or U.S. citizenship. 

This is a remote position.  Must reside in California.  

What You Will Be Doing:

Under limited supervision, the Chief Health Services Officer is responsible for providing strategic direction across HPSJ Health Services functions, consistent with contractual and regulatory requirements, and HPSJ strategies and objectives. Health Services functions include Utilization Management, Case Management, Behavioral Health & Social Work, Quality Management, Quality Improvement and Health Equity, Health Education, HEDIS & NCQA, and Grievance and Appeals. Work is varied, complex and requires a high degree of discretion and independent judgment. 

Supervises  

• Executive Director of Health Services 
• Directors of Health Services (select) 
• Director of Special Projects Quality 
• Director, Strategic Initiatives and Programs 
• Managers of Health Services (select) 
• Executive Assistant 

Essential Functions:

• Oversees operational objectives and plans; ensures the development and implementation of associated business plans and tactics. 
• Anticipates the need for, develops and implements relevant and effective care for utilization management, care management, social work and behavioral health programs. 
• Anticipates, identifies, analyzes and reports on care opportunities, issues and trends; makes appropriate recommendations; develops and implements agreed upon changes. 
• Collaborates with the Chief Medical Officer in the strategic planning, implementation and oversight of the Quality Improvement and Quality Management Programs. 
• Collaborates with the Chief Medical Officer and Medical Director(s) in identifying medical service issues that have an impact on plan benefits and their administration; provides direction in resolving medical claims review, grievances, appeals, and other Health Services issues. 
• In collaboration with the Chief Medical Officer, will ensure consistent application of medical criteria to utilization management decision making. 
• Collaborates with internal and external stakeholders to develop programs that increase awareness and provide educational opportunities to providers and members regarding HPSJ’s Quality Improvement and Health Equity Transformation Program goals and activities. 
• Ensures collaboration among Health Services teams and other teams with a focus on Member care. 
• Works collaboratively with all departments across the organization to achieve health equity goals established by NCQA, CMS, DHCS and DMHC, and partners with the Quality team to ensure that the QIHETP program is implemented and monitored to meet or exceed CMS, DHCS, DMHC and NCQA requirements. 
• Ensures organizational policies, procedures, and programs consider health inequities and are designed to promote health equity where possible, including but not limited to: Marketing strategies, medical and other health services policies, member and provider outreach, Community Advisory Committee, quality improvement activities, including delivery system reforms, grievances and appeals, and utilization management. 
• Oversees the development and implementation of policies and procedures aimed at improving health equity and reducing health disparities. 
• Oversees the development of targeted interventions designed to eliminate health inequities. 
• Develops quantifiable metrics that can track and evaluate the results of the targeted interventions designed to eliminate health inequities. 
• In collaboration with Compliance and other responsible business areas, ensures staff, subcontractor, downstream subcontractor and network provider staff receive mandatory diversity, equity and inclusion training, as specified in the CMS and DHCS contract; including review of training materials to ensure materials are up to date with current standards or practice and maintaining records of training completion. 
• Co-chairs the Quality Improvement and Health Equity Transformation Committee and oversees the development of a Health Equity Annual Report. 
• Serves as a representative and spokesperson for HPSJ in support of Quality and Health Equity with key county partners. 
• Participates in State and industry work groups such as DHCS, DMHC, CHCF, NCQA, ACAP and CAHP to expand HPSJ’s influence on benefit design, regulations, and policy direction. 
• Conducts or oversees the preparation, implementation, and corrective action plans for internal and external audit activities to ensure practices adhere to adopted guidelines, NCQA requirements, regulatory guidelines and HPSJ criteria. 
• Develops or oversees the development of relevant, timely and accurate internal and external quality and health equity reports, advising leadership as appropriate. 
• Oversees quality concern trends identified through the QI process, including corrective action plans. 
• In collaboration with the Chief Medical Officer, will identify medical delivery system quality issues; develops and oversees implementation of corrective action plans. 
• Oversees the preparation of and participates in regulatory audits and external review activities; develops and monitors corrective actions plans. 
• Oversees routine and ad hoc internal audits and corrective action plans to ensure practices adhere to applicable regulatory and accreditation requirements and HPSJ criteria. 
• Oversees the development of relevant, timely and accurate internal and external reports. 
• Develops and manages department budgets; implements appropriate interventions. 
• Oversees the collection, storage and retrieval of relevant data and information. 
• Oversees the development, implementation and maintenance of appropriate and required records, documents, policies and procedures. 
• Promotes, and ensures that direct reports promote an environment that supports and encourages the adoption of HPSJ’s stated values. 
• Hires, develops and retains, and ensures that subordinate managers hire, develop and retain, a competent staff; coaches and mentors the leaders on the Health Services team. 

What You Bring:

Knowledge, Skills, Abilities and Competencies  

Required 

• Expert knowledge of and proficient skills in administering clinical operations protocols. 
• Expert knowledge of regulatory requirements for Medi-Cal and Medicare pertaining to utilization management, case management and behavioral health. 
• In depth knowledge of and ability to identify, implement, monitor and analyze relevant metrics models, and implement effective interventions based on results. 
• In-depth knowledge of standard contract components and contract language specific to healthcare. 
• In-depth knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them. 
• In-depth knowledge of medical management information systems and their interrelationships.  
• In-depth knowledge of health equity and diversity principles, concepts and best practices. 
• Strong knowledge of general medical policy benefits and exclusions. 
• Strategic mindset: ability to translate strategic concepts into actionable business plans. 
• Very strong project management skills, with the ability to function as a sponsor and owner on complex projects; a track record of successful large project implementations. 
• Very strong facilitation, negotiation and conflict resolution skills. 
• Strong skills in budget development and management. 
• Very strong collaboration skills with demonstrated ability to create and foster a collaborative work environment, maintain effective, high-performance teams, and organize people and resources to solve problems and identify business opportunities. 
• Very strong interpersonal skills, with the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of HPSJ. 
• Very strong oral and written communication skills, with the ability to communicate professionally, effectively and persuasively to diverse individuals and groups inside and outside of HPSJ; includes the ability to effectively explain complex information. 
• Very strong presentation skills, with the ability to tailor presentations to a specific audience, and address and interact with large groups. 
• Strong customer service skills. 
• Intermediate mathematics skills, including basic algebra. 
• Intermediate skills in Word, Excel and Outlook, including the ability to develop spreadsheets, formulas, and create tables and graphs. 
• Ability to articulate and embrace organizational values, integrate into management practices, and foster their manifestation among staff. 
• Promotes, maintains, and ensures that direct reports promote and maintain an environment that supports HPSJ’s strategy, vision, mission and values. 
• Very strong coaching/counseling skills, including the ability to function as a mentor to management and employees. 
• Ability to speak and be understood in English. 
• Ability to handle confidential information with appropriate discretion. 

Preferred 

• Strong clinical skills.