Vice President, Utilization Management & Case Management - Medicaid Job at S

Sentara Health is recruiting a Vice President, Utilization Management and Case Management - Medicaid to work in Virginia! Sentara Health Plans is a full-service health plan with products for groups and individuals, as well as Medicaid and Medicare including Special Needs (SNP) plans. We have grown from a regional health plan into a formidable alternative to national carriers in Florida and Virginia, covering close to one million members. In Florida, we offer commercial group, individual, and Medicare Advantage plans through AvMed, and we also offer a Florida-based provider services network (PSN) through Sentara Care Alliance, a partnership between Universal Health Services, Inc., and Sentara Health. In Virginia - where Sentara Health Plans is headquartered - we offer health insurance through our extensive state-wide network, which includes operating as part of an integrated delivery network (IDN) with Sentara Health hospitals and providers. Sentara Health Plans, previously known as Optima Health Plan, has been offering health coverage since 1984. Sentara Health Plans is the health plan division of Sentara Health, an integrated, not-for-profit health care delivery system that was itself founded in 1888. Sentara Health is one of the largest health systems in the U.S. Mid-Atlantic and Southeast, and among the top 20 largest not-for-profit integrated health systems in the country. Over 130 years after its founding, Sentara Health continues to achieve operational excellence and to pursue its central mission - "we improve health every day." The Vice President, Utilization Management and Case Management - Medicaid is responsible for oversight of Sentara Health Plans' Government Program Clinical Care Services (CCS) programs including Medicaid, Medicare, LTSS, and the Medicare Dual Special Needs Plan (DSNP). Clinical Care Services includes direct Clinical Care Coordination and Case Management, Behavioral Health, Disease Management, Utilization Management, and Clinical Pharmacy Management, according to State and Federal regulations, and contracted services including the Model of Care. Provides strategic and operational leadership to the CCS workforce in delivering innovative and excellent quality clinical support programs and services to Plan members with the goal of improving health every day. Maintains a solid grasp of the national healthcare industry, best practices, and provides leadership to program design and development. Works closely with the VP, Clinical Care Services Commercial and Shared Services to ensure coordination, collaboration, and program consistency across Clinical Services. Represents Sentara Health Plans as a senior leader with state and federal government programs, and across the integrated Sentara Healthcare team. Accountable for managing the medical/loss ratio within the Health Plans' vision, guiding principles, and financial objectives. Experience and Education: Case Management experience is defined as management Case Management and/or Utilization Management functions within a health plan specific to government programs (i.e. Medicaid, Medicare, DSNP, LTSS, etc.). Graduate of an accredited school of clinical practice such as professional nursing, counseling, or social service. All licenses must be maintained in area of specialty. #J-18808-Ljbffr