VP of Medical Management

Job Description:

The Vice President of Medical Management – Managed Care (VP) is a member of the executive management team. This position has responsibilities across multiple geographies.  In addition, the role will drive Operational accountability initiatives for Medical Management. The position provides strategic direction, leadership and oversight for Medical Management programs including: Utilization Management (UM), and Complex Case Management (CM).  Provides leadership to and is accountable for the performance and direction through multiple layers of management and senior level professional staff. The VP is responsible for coordinating with appropriate personnel to meet operational program needs, ensures compliance with state requirements and client requirements. Provides long-term planning and oversight to ensure activities are appropriately integrated into strategic direction and operations, as well as the mission and values of the company.

Job Duties & Essential Functions:

• Directs the development, planning and execution of continual process improvement efforts, policies, procedures, and regulatory compliance functions related to care management activities
• Provides vision and leadership to advance the care management program under WellMed to the next level of service
• Collaborates with leadership to execute the implementation of the medical management programs as defined by AWPRx  Provides information/data to market leadership as requested
• Promotes understanding, communication and coordination of all medical management programs components
• Provides oversight for all activities related to delegated and regulatory requirements including: annual health plan delegation audits
• Drives adoption of best practices and trends for UM, CM, DM activities
• Monitors/analyzes metrics/data/trends, and ensures areas needing attention are communicated to  applicable stakeholders
• Drives UM performance to meet targets for total pharmacy costs
• Assists with the development of the UM Work Plan, Evaluation and the monitoring of the Work Plan activities as they related to clinical performance improvement
• Develops operating budget as necessary and participates on various teams, committees and meetings at AWPRx
• Drives and assists in the design of strategic plans and management of large-scale clinical initiatives, pilots, and projects promoting quality care

Job Qualifications:

• Education:
  • Current, unrestricted clinical license(s)
  • Qualifications to perform clinical oversight for the services provided
  • Post-graduate experience in patient care
  • Board certification (if the senior clinical staff person is an M.D. or D.O.).
  • BS in Pharmacy preferred, Unencumbered licensure to practice Pharmacy in state of employment
• Experience:
  • Minimum experience in the Workers Compensation Industry of 10 years.
  • Four (4) years management and clinical pharmacy experience required. Two (2) to four (4) years Pharmacy Benefit Management (PBM) or managed care experience preferred. Previous director experience preferred.  
• Supervisory experience: N/A
• Other competencies or skills: N/A
• Background Checks/Licensing Requirements:
  • Initial credentials will be verified, re-verification at least every three years, staff notification of adverse changes in licensure/certification status, and the corrective action for loss of certification or license.
  • All credentials are tracked via the User record in ForceRx, for documentation of licensure, certification, and continuing professional education.