The Market Medicaid Leader is the voice of Medicaid internally andexternally.
Reporting to the Senior Vice President, National Medicaid and the MAS VPof MSBD, the Market Medicaid line of business leader is responsible for the overall performance of the market Medicaid line of business program, with a focus on financial performance and membership growth. Oversees all aspects of market Medicaid programs, state contracting arrangements, product development, compliance with State and Federal Policies and requirements, and partnerships with market [Permanente] and Administration. Strategically builds, manages and sustains external business relationships, particularly with state and local regulators. Accountable for product development, administrative processes, interdepartmental communication, and regulatory requirements. Develops an annual strategic plan and updates market and National Executive Sponsorship on strategic issues/development, business performance, and progress against objectives. Demonstrated passion and creativity in developing models of care serving low income vulnerable populations.
- Position the market as the leader for quality, care delivery for high need vulnerable populations. The position is responsible for customer experience, achieving membership growth targets, overseeing the Medicaid product portfolio (TANF, ABD, LTSS and Adult Expansion), and developing/executing market Medicaid strategy based on state and CMS requirements, national standards and alignment with overall national and market strategy. This position incorporates care delivery requirements into strategy and develops a strong partnership with medical group and health plan delivery system operations and quality.
- Demonstrated strategic thinking with ability to balance long-term direction with need for immediate impact and results. Maintain awareness of the competitive landscape and market trends. Develop capacity to identify new business opportunities for the market to expand its Medicaid footprint. Recognize industry trends and Identify initiatives for market to demonstrate innovation, which could take the form of creative partnerships, marketing, member retention, care delivery or delivery system improvements, or participation in innovative projects managed by the federal government, community or provider partners.
- Ensure market Medicaid plans adhere to national guidance and are aligned with market business strategies, goals and initiatives and lead development of annual market Medicaid membership targets with market forecasting lead. Participate in market forums to ensure alignment of Medicaid strategies with market business plans and assure full integration of Medicaid where applicable; participate in other market forums and serve as the market voice of Medicaid. Serve as principal contact within the region for Medicaid and interface regularly with market executives (MSBD, CFO, HManage the relationship and activities with functional areas as business, regulatory, operations, legal and IT.
- Market Medicaid Operations
- Manage the relationship and activities with functional areas as business, regulatory, operations, legal and IT. Oversee and coordinate the validation and submission of state required reports and work in collaboration with NMER for timely, accurate and complete submission of encounter data. Coordinate resources so that they leverage/align with other initiatives through the organization. In conjunction with National Medicaid implement market geographic and product line Medicaid expansions. Set key performance metrics and ensure that the Medicaid line of business is well-served and drive continuous improvement initiatives related to Medicaid.
- Stakeholder Outreach
- Represent KP with state regulators, departments and representatives as well as local health departments and community-based organizations. Proactively anticipate and respond to state and federal initiatives which impact Medicaid. Manage contractual arrangements with the states, local Departments of Health, and providers including, but not limited to, transportation providers, School Based Health Centers, Federally Qualified Health Centers and CSBs.
- Medicaid compliance and regulatory
- Maintain a deep understanding of state and CMS Medicaid regulations, collaborate with National Medicaid Compliance to ensure all market functions are aware of and compliant with state and CMS Medicaid requirements. Identify market compliance risks and escalate issues as necessary to market and national Medicaid compliance and line of business leaders. Lead State Medicaid audits. Accountable for market remediation of compliance risks with market functional leaders, as needed.
- Financial Accountability, State Medicaid Capitation and Rate Development
- Accountable for the market Medicaid line of business P&L and department budget. Coordinate the market development of rate development templates for annual capitation rates. In conjunction with Actuarial services and Finance represent the market in capitation rate negotiations. Identify revenue and expense opportunities for increased state reimbursement and internal, fiscal improvement opportunities.
- Lead and develop market Medicaid LOB staff
- Ensure market line of business structure is designed to achieve desired outcomes based upon best practices. Hire, onboard, develop and coach market Medicaid staff to sustain a strong and diverse talented team and advance Medicaid performance. Provide opportunities for market staff to learn about the national Medicaid line of business and functional areas to contribute to building their expertise and expand their view of the business line. Ensure leadership succession plans are in place so that key positions can be backfilled with appropriate talent.
- Minimum ten (10) years of relevant experience in a Medicaid managed care organization.
- Minimum seven (7) years of management experience.
- Minimum five (5) years in product line management to special populations.
- Bachelors degree or four (4) years relevant experience.
- High School Diploma or General Education Development (GED) required.
License, Certification, Registration
- Strong background working with Medicaid and/or Special Populations and unique health care needs.
- Understanding of state and federal Medicaid framework and regulatory requirements
- Excellent negotiation skills, verbal/written communication skills.
- Strong analytical and strategic planning skills.
- Excellent public presentation skills.
- Strong persuasive and interpersonal skills.
- Knowledgeable of Medicaid health care delivery systems
- Knowledgeable of current trends in care management an industry related to care delivery to Medicaid population.
- Demonstrated ability to build effective partnerships and influence others who may have different perspectives.
- Must be a decisive, results-oriented manager or people. Must excel in developing a highly focused, cohesive team of professionals who are comfortable working in a team environment.
- Demonstrated ability to work in a highly matrixed environment.
- Strong collaborative and team skills.
- Twelve (12) years of relevant experience in a Medicaid managed care organization preferred.
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