Job Summary

Responsible for the vision, strategy, planning, execution, performance, compliance and communication of the Specialty Products Dedicated Services Unit (DSU) related to the health plan's Medicare and long-term care operational line-of-business. Exercises strategic control over planning short and long-term fiscal viability of the organization in addition to formulating and administrating policies.  As a change agent, works collaboratively with the SSO and Customer Service departmental management to inject new service behaviors and capabilities for this specific member population and to promote the adoption of these services in the health plan’s core Medicaid business where appropriate.

Primary Responsibilities

• Direct and effectively develop strategic goals into specific operating and business plans and decisions to service the Specialty Products Markets.
• Responsible for providing support and leadership in the integration and expansion of programs for dual eligible and long-term care members.
• Provide leadership, direction and skill development to direct reports; create streamlined workflows and market specific policies.
• Develop the appropriate retention and provider issue resolution strategies to create and sustain a model of providing a unique member/provider experience. Responsible for member retention activities.
• Develop collaborative relationships with key partners to enhance member retention and provider satisfaction through a fully empowered workforce.
• Establish and maintain continued accuracy and efficiency improvements through automation and increased autoadjudication.
• Responsible for establishing appropriate tracking and reporting metrics for provider/member touch points.
• Responsible for end to end focus and accountability from sales/enrollment, provider set-up, customer service and claims payment. 
• Ensure tighter coordination of benefits and cross-over claims for dual eligible’s.
• Active client/customer relationship management including the development and implementation of strategic partnership growth initiatives.
• Ensure regulatory compliance.

Education

Required:
Bachelor’s Degree in related field.

Preferred:
Master’s Degree in Health Care or Business Administration.

Years and Type of Experience

14 years relevant work experience and at least 10 years of leadership/management experience.
Specific Technical Skills

• Comprehensive knowledge of individual commercial insurance delivery system and how they can work to improve quality of care and reduce costs.
• Strong financial management skills.
• Excellent organizational and analytical skills. 
• Proven negotiation skills.
• Proven project management skills with a demonstrated ability to establish and complete plans successfully.
• Excellent team-building and staff management and development skills are essential.
• Excellent communication skills, both verbal and written.
• Ability to understand major objectives and break them down into meaningful action steps.
• Ability to understand business strategy and formulate concise solutions to problems. 
• Proven ability to affect change and meet business goals, monitor progress and take corrective action when necessary. 
• Proven ability and prior experience with negotiating and maintaining public and legislative relationships.
• Ability to interact with all levels of personnel and management throughout the organization.

Required

• Have the requisite interpersonal skills to manage without direct reporting relationships in a matrix management environment.
• Strong knowledge of operations.
• Ability to analyze risks and opportunities and respond effectively.
• Ability to read, analyze, and interpret contracts, regulations, common policies and procedures, reports, and legal documents.
• Ability to develop, modify and utilize project management tools and methodologies.
• Ability to manage and prioritize multiple existing and emerging projects
• Understanding of service delivery and developing a portfolio of services unique to this line of business.

Additional Information

Direct Reports:  6
Indirect Reports:  70
Budgetary Responsibility:  $3.5M
Must be able to travel 20% of time to attend meetings and visit health plan facilities.