Health Plan Director
Las Vegas, NV, USA | American Nurses Association
Industry:Non-Profit / Social Enterprise
Operations / Production
Job Description:71 people have viewed this job
The Las Vegas Metropolitan Police Department Employee Health and Welfare Trust is currently seeking applications from qualified individuals for the salaried, full-time, overtime-exempt position of Health Plan Director. The position is at-will and will not be subject to an employment contract.
Note: The Health Plan Director is not an employee of the Las Vegas Metropolitan Police Department. It is not a civil service position and does not include participation in the Nevada PERS retirement system.
Please be advised that all applicants will be subject to a comprehensive background check. In addition, this position is subject to initial and random drug testing.
This position provides direct oversight of Trust operations in accordance with the policies, practices and procedures established by the Trustees of the Health and Welfare Trust. The Health Plan Director reports directly to the Board of Trustees and is responsible for all aspects of global health benefit program and vendor management, administration, and analysis.
Bachelor’s degree (or equivalent work experience), preferably in a healthcare or business-related field. The ideal candidate will have a bachelor’s degree in nursing and hold a current valid state RN license. Advanced degrees such as Masters in Nursing, Healthcare Administration, Organizational Development, Business Administration, or related field, also preferred.
Minimum of 5 years’ experience preferably in a health plan environment providing a strong financial understanding of healthcare delivery systems and the performance of those systems, and providing a strong working knowledge of utilization review and case management, provider contracting, physician profiling, pharmacy programs, and performance improvement. Experience in the local healthcare environment and clinical experience is a plus.
Significant professional experience, preferably a minimum of 5 years with a strong working knowledge of operations, claims, enrollment, and general administration associated with managing a health plan and health benefits.
Strong understanding of healthcare trends and statistical measures of healthcare performance.
Familiarity with trusteed “union” benefit plans and/or managed care environments preferred.
Strong understanding of current benefits legislation, e.g., ACA, CARES Act, COBRA, HIPAA, etc.
Experience utilizing strong analytical skills to interpret a strategic vision into an operational model.
Strong business acumen and experience in addressing issues in the area of finance, strategic planning, budgeting, project management, and marketing that affect health plans and an ability to forecast, anticipate, and respond to trends and challenges and work collaboratively to address them in alignment with organization goals and strategies is preferred.
Experience in managing vendors/vendor relationships is preferred. High degree of focus and attention to participant service excellence.
Required Skills /Abilities:
Intermediate level computer skills (e.g., Word, Excel, Outlook, etc.).
Excellent professional communication (written and oral) and presentation skills.
Ability to work independently, handling multiple related tasks, prioritize and meet deadlines and work independently.
Must possess a strong sense of urgency and ability to deal with very sensitive issues in tactful, positive, confidential manner.
Collaborative relationship building and interpersonal skills.
Leadership qualities that reflect the Trust’s mission, vision, and values.
Flexibility and maturity, including a demonstrated ability to successfully manage complex situations in an environment that experiences rapid growth and change.
Demonstrate good judgment in decision making through a combination of analysis and experience.
Think strategically, anticipate future consequences and trends, and incorporate them into the organizational plan.
Develop and streamline processes that ensure efficient, high quality operations.
Project management experience, as well as the ability to delegate.
Advanced degree of independent judgment and ability to work with little direction.
Be responsive, take directions well, anticipate needs of Trustees, etc.
Enforce accountability, lead from the top down, and learn the strengths and weaknesses of the team so as to position people to succeed.
Demonstrate strong track record in improvement of healthcare value for health benefits plan participants and sponsors.
Evaluate, analyze, and provide feedback regarding Trustee and/or professionals’ initiatives.
Communicate effectively with Trustees who have less technical healthcare background and less time for detail.
Deliver presentations in a professional and effective manner to a variety of audiences.
Manage competing deadlines and multiple projects in a fast-paced environment.
Provide consultative technical expertise, advice, and guidance regarding benefits matters to Trustees. Communicate policies, practices, and guidelines effectively to all levels of the organization.
Ensure all programs are progressive, competitive, cost effective, high quality, equitable and flexible.
Monitor vendor performance and identify areas where new/improved benefit plans/processes can improve the quality of existing benefit services, as well as recommending future opportunities.
Manage identification, selection and partnership with administrative and service vendors including governance, contract compliance, issues management, communication frequency, schedule, and approach.
Job Functions / Description:
Work with the Plan Administrator and Board of Trustees to set goals, clearly define operations, and develop appropriate performance standards, metrics, and reporting tools to monitor the operations of the Trust.
Provide executive leadership by directing and coordinating activities consistent with established objectives, compliance and quality requirements, and policies and procedures.
Plan, develop, and implement operational strategies and action plans to ensure that goals are met.
Establish and maintain effective working relationships with business partners to ensure operational efficiencies, drive superior participant service, and adherence to contractual requirements.
Monitor cost and utilization of benefits.
Assist and support with care coordination of services between Primary Care Physician (PCP), specialists, medical providers, hospitalists, and nonmedical staff as necessary to meet the needs of participants. Coordination of care services as needed include the following:
Assist the patient to find a family doctor and specialist.
Advise the patient to get ready for surgery.
Help the patient to acquire the care needed at the hospital and Emergency Room.
Assist with the transition when the patient is released out of the hospital.
Help to coordinate care if the patient has a chronic disease (e.g., COPD, diabetes, heart problems, high blood pressure, kidney disease, etc.).
Monitor progress towards patient and Trust satisfaction goals. Respond and resolve complaints and issues from participants.
Review of preventative screening (annual exams, testing, immunizations) and recommend actions.
Review clinical, condition-specific gaps in care and recommended actions to those gaps.
Support participants with prior authorization needs, including proactive review of benefit coverage and prior authorization requirements as well as outreach to providers to initiate the authorization if appropriate.
Administer plan enrollment activities (e.g., new hire in-processing meetings, Associations new hire meetings, annual open enrollment, etc.) associated with enrolling new participants and educating them in Trust health benefits.
Present educational meetings including retiree benefit that represent employees covered by the Trust.
Administer and organize annual health fair and flu shot clinic.
Design and direct wellness and prevention efforts including the research of and implementation of best practices and subsequent monitoring of such efforts.
Guide and assist Trustees in the development, monitoring and internal controls associated with managing and monitoring the financial aspects of the Trust’s programs and services.
Initiate, implement, and monitor activities aimed at reducing costs, increasing accuracy and efficiency, and increasing both internal and external participant satisfaction.
Ensure that all Trust activities and operations are carried out in compliance with local, state, and federal regulations and laws governing non-ERISA public employee benefit plans, solid business practices, and internal policies.
Promote ongoing organizational commitment to effective communication with Trust participants, employers, local unions, vendors, and providers, to ensure participants are afforded every opportunity for quality service and benefits utilization.
Lead activities associated with Board of Trustee meetings including meeting planning, contract negotiations, attendance, material preparation, minute taking, etc.
Serve as a Trust representative in Las Vegas Health Services Coalition activities and assume leadership role on issues relevant to Trust operations.
Perform other duties as assigned within the scope of responsibilities and requirements of the job.
Manage financial recordkeeping, employee eligibility, employer contributory reporting.
Manage and facilitate written communications to Trust participants.
Handle internal claim appeals and submit recommendations to Trustees / Appeals Committee as necessary.
Work collaboratively with other professionals serving the Trustees of the Plan.
Serve as the HIPAA Compliance Officer/Privacy Official responsible for implementing safeguard that protect the confidentiality, integrity and availability of any form of protected health information generated or maintained by the Trust.
Produce well-written analytic summaries appropriate for presentation to Trustees.
Design, implement and monitor health plan internal control system including management of the plans external audit process.
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