Director, Senior Continuum Services

The Senior Director of Continuum Services, is responsible for the development, planning, management, and integration and delivery of Kaiser Foundation Health Plan Continuum of Care operational system processes and standards of practice, in alignment with the organizations mission, strategic business plan, and related performance improvement expectations.

• In collaboration with Regional Continuum of Care Administration, achieves/exceeds performance expectations for all areas of continuing care operations, including, but not limited to all outside medical services; hospital, Home Health, Hospice, SNF, DME, Ambulance, Claims and Referrals, Palliative Care, ESRD, Inpatient and Outpatient Psychiatry, Case Management, Continuing Care Utilization Management, Health Plan Benefit Application, Contracting, Emergency Care Management.
• In collaboration with local and regional leadership, defines and communicates strategic objectives and scope. Articulates issues or problems from broader organizational/mission perspective.
• Creates the structure and processes to develop, implement and evaluate programs, policies and standards for continuing care services to ensure coordinated plans of treatment, delivery systems that meet member needs, and cost effective utilization of necessary services without delay.
• Ensures the integration of quality, service and efficiency improvements into day-to-day operations.
• Establishes appropriate methods to define, categorize, and monitor claims and referred services. Provides oversight to the data and reporting systems used to track the performance of continuing care operations.
• Works collaboratively with medical group and labor leadership to recommend service delivery changes or internalization of services where appropriate.
• Hires and develops highly skilled and qualified direct reports and staff. Provides leadership development opportunities and counseling for direct reports and other delivery system leaders. Coaches, manages and leads a staff dedicated to providing subject matter expertise, customer service, and high quality care without delay.
• Works with regional and service area leadership to establish appropriate case management programs to monitor and manage the care of members in non-KFH facilities.
• Ensures the successful operational implementation of HealthConnect continuing care functionality.
• Responsible for the efficient delivery of all continuing care services for KP members by overseeing the development, negotiation, and utilization of cost-effective, high quality contracts with outside providers.
• Establishes joint contracting relationships across medical centers where appropriate. Establishes policies, procedures and protocols for the reimbursement of claims submitted by KP members for outside services to maximize reimbursement revenue from other insurers (e.g., Medicare or Medicaid) with consistent appropriate interpretation and application of the health plan benefit.
• Monitors and assesses trends, external environment and internal practices; makes recommendations to develop and adjust strategy to meet the changing business and market conditions.
• Builds relationships with local leadership and community partners to develop and meet utilization targets and related quality goals in the Continuum.
• Sponsors clinical pathway development, implementation and evaluation.
• Contribute to the development of strategic plans to facilitate the Mid-Atlantic region reaching and exceeding its goals for effective management of patient day rate (PDR) and outside medical costs.
• Host regular Joint Operations Committee meetings with key vendor partners, including the areas of transportation, DME, as well as participate in UM JOCs with core hospitals, national buy to pay, SNF, HH, HO, Dialysis, and other strategic partners.
• Builds the case for change and articulates costs and risks for not making change. Champions new ways of meeting targets and/or goals. Explores critical issues not explicitly addressed by others. Anticipates and plans for future issues or problems.
• Assures short and long range financial goals are met be establishing and controlling continuing care expenses in support of the overall financial plan.
• In conjunction with regional and service area leaders, develops strategies for determining the most cost-effective, efficient levels of continuing patient care clinically and operationally.
• In collaboration with finance and operational partners stakeholders, establishes appropriate mechanisms to collect and analyze data on care delivered outside of the KP integrated system.
• Ensures KFHP compliance with UM standards and requirements in the Continuum. Coordinates with facility based leadership to develop systems to ensure the seamless transition of patients through different care settings. Where capacity or resource constraints exist, works with regional and local leadership to identify opportunities to coordinate contracting efforts for outside medical services.
• Ensures the successful implementation of promoting, and operationalizing the Labor-Management-Partnership throughout the organization. Achieving key LMP initiatives and ensuring the demonstration of LMP behaviors throughout the organization. Ensuring labor participation in appropriate decision making forums and committees.
  

• Minimum ten (10) years of experience in clinical and managerial roles in a multi-faceted health care system and multi-service provider setting required.
  

• Bachelors degree in health services or business administration, public health, hospital, nursing, or related health care discipline required.
  

• N/A
  

• Advanced Ability to communicate and make recommendations to upper management required.
• Advanced Demonstrated time management and priority setting skills required.
• Demonstrated ability to function collaboratively in a multi-entity partnership environment.
• Able to lead and manage through influence and change.
• Able to manage various stakeholder interests and demonstrated skills in facilitation, problem solving, decision making, persuasion and team-orientation.
• Thorough knowledge of quality assurance, resource management, health plan regulatory and licensing processes including federal and state laws and regulations.
• Demonstrated expertise in project management, problem solving, verbal and written communication and collaborative working skills.
• Advanced Ability to lead/manage others required.
• Advanced Demonstrated problem-solving skills required.
• Advanced Demonstrated interpersonal/verbal communication skills required.
• Advanced Demonstrated negotiation skills required.
• Advanced Knowledge of community, state and federal laws and resources required.
• Advanced Demonstrated written communication skills required.
• Advanced Ability to effectively present information and responds to questions from families, members, and providers required.
• Advanced Ability to effectively present information and responds to questions from peers and management required.
• Advanced Knowledge of healthcare delivery required.
• Advanced Ability to lead/manage others in a matrixed environment required.
• Advanced Ability to implement process improvements required.
• Advanced Other Strong clinical knowledge of broad range of medical practice specialties required.
  

• Masters degree in one of the aforementioned fields preferred (health services or business administration, public health, hospital, nursing, or related health care discipline).
• Current valid RN, PT, OT, ST license preferred.
• Utilization Management experience.