Director of Health Services - Ventura County Health Care Plan

About the role

Under general direction of the Health Care Plan Administrator, responsible for managing the daily operations of the Quality Assurance, Utilization Management, and Case & Disease Management departments within the Ventura County Health Care Plan. Provides strategic oversight of clinical operations, quality improvement, and regulatory compliance under the Knox-Keene Act, Title 28 CCR, and Department of Managed Health Care (DMHC) requirements.

Responsibilities

• Directs oversight and responsibility for Quality Assurance, Utilization Management, and Case & Disease Management department deliverables
• Provides strategic oversight of clinical operations, quality improvement, and regulatory compliance as it relates to clinical operations
• Develops policies and procedures for assignment area
• Ensures compliance with Federal and State regulations, including Knox-Keene Health Care Service Plan Act, Title 28 California Code of Regulations, Department of Managed Health Care (DMHC) requirements, and National Committee for Quality Assurance (NCQA) accreditation standards
• Prepares and oversees the development of management reports, tracking and trending analyses, and other data-driven evaluations to support decision-making and performance improvement
• Collaborates with the Medical Director and supervising clinical staff to ensure appropriate medical policies and clinical guidelines are utilized when making determinations related to authorization requests
• Assists staff in making complex clinical decisions, through appropriate use of policies/procedures and Plan Administrator or Medical Director input
• Provides clinical oversight of Case Management and activities related to Healthcare Effectiveness Data and Information Set (HEDIS) measures and interventions
• Provides leadership and oversight of Health Care Plan personnel through recruiting, hiring, training, mentoring, and evaluating licensed clinical professionals and administrative staff to achieve departmental and organizational objectives
• Guides organizational and regulatory changes, ensuring consistent implementation of new programs, policies, procedures, and care management strategies
• Maintains updated internal operating procedures
• Led and participates in all required committees and sub committees including, but not limited to Quality Assurance, Pharmacy and Therapeutics, and Utilization Management
• Develops and implements departmental performance improvement indicators and goals
• Performs other related duties as required

Requirements

• A typical combination would be equivalent to A bachelor’s degree from an accredited college or university in business, public health, nursing, health administration, or a closely related field AND Five (5) years' experience in progressively responsible health care administration/management
• At least two (2) years of direct supervision and personnel management experience
• Demonstrated knowledge of Knox Keene Act, Department of Managed Health Care (DMHC) regulations and Healthcare Effectiveness Data and Information Set (HEDIS)

Qualifications

• Comprehensive knowledge of: trends and changes in the health care and insurance industries; health care plan policies and procedures; knowledge of Knox Keene Act, DMHC Regulations and HEDIS; principles and practices of personnel administration, supervisory, and management techniques; theory, techniques, and practices of professional nursing; and program evaluation methods, data collection, analysis and report writing procedures.
• Comprehensive ability to: direct the work of others performing service delivery in assigned health care plan specialty areas; collaborate effectively; analyze statistical data and implement changes based on findings, problem solve and make sound decisions; represent the department on assigned committees and with service providers; establish and maintain effective working relationships with staff and health care professionals at all levels, both internal and external to the department, as well as with the general public; and communicate clearly and concisely, both orally and in writing.