VP, Utilization Management and Quality Improvement
Avalon Healthcare Solutions
Avalon Healthcare Solutions, headquartered in Tampa, Florida, is the world’s first and only Lab Insights company, bringing together our proven Lab Benefit Management solutions, lab science expertise, digitized lab values, and proprietary analytics to help healthcare insurers proactively inform appropriate care, reduce costs, and improve clinical outcomes. Working with health plans across the country, the company covers more than 36 million lives and delivers 7-12% outpatient lab benefit savings. Avalon is pioneering a new era of value-driven care with its Lab Insights Platform that captures, digitizes, and analyzes lab results in real time to provide actionable insights for earlier disease detection, ensuring appropriate treatment protocols, and driving down overall cost.
Studies show that 30% of clinical laboratory testing is unnecessary or overused. Inappropriate testing or missing a key screening can lead to complications and expense arising from unwarranted care, or not obtaining proper care when needed, leading to increased health risks and costs. Avalon helps ensure delivery of the right test, at the right time, and in the right setting. We seek to ensure the most effective patient treatment, improve clinical outcomes, and optimize cost and affordability.
Avalon is a portfolio company of Francisco Partners, a global private equity firm that specializes in investments in technology and technology-enabled service companies.
Avalon is a high growth company where every associate has an opportunity to make a difference. You will be part of a team that shapes a new market and business. Most importantly, you will help Avalon to achieve its mission and improve clinical outcomes and health care affordability for the people we serve.
For more information about Avalon, please visit www.avalonhcs.com.
Avalon Healthcare Solutions is proud to be an equal opportunity employer including disability/veteran. We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity or Veteran status.
Avalon Healthcare Solutions provides and maintains a drug-free workplace for its employees.
For more about Avalon, please visit our web site at http://www.avalonhcs.com.
About the Vice President, Utilization Management and Quality Improvement:
Reporting to the Chief Operating Officer and as a member of the Senior Leadership Team, the VP, Utilization Management, Appeals and Quality Improvement (VP, UM/QI) will work cross-functionally across the organization to ensure Avalon is meeting or exceeding all contractual performance metrics. In addition, this role will directly manage the UM and QI teams. Also, the VP, UM/QI will serve as a genetic testing management subject-matter expert to prospects and clients.
This position is eligible for remote work, but quarterly travel to the corporate office in Tampa, Florida may be required.
Vice President, Utilization Management and Quality Improvement - Overview of Main Responsibilities:
Utilization Management/Preservice Review/Post-Service and Appeals:
- Manage and develop the clinical and administrative UM staff to ensure lab services are medically appropriate for Avalon’s clients
- Provide oversight for Avalon’s Utilization Management Program
- Serve as a liaison between Physician Review team and UM nursing team
- Oversee enhancements to internal clinical review systems and applications
- Serve as a liaison between the UM/QI teams and the Implementation team
- Operational oversight of external vendors: letter production, offshore/contract resources, etc.
- Participate in the Clinical Advisory Board workgroup as requested
- Provide ongoing development of and support to the QI department.
- Oversee all aspects of maintaining NCQA accreditation.
- Participate in delegation/accreditation audits/reviews.
- Lead and facilitate Avalon’s quarterly QIC meetings.
- Establishes an annual QI work plan.
- Deploy meaningful actions that maximize Avalon’s potential to meet and exceed SLAs and KPIs.
- Track and report on all quality performance indicators.
Plan/implement/manage UM/QI Operations programs and strategies:
- Establish and implement internal and/or external service level agreements (SLAs) and ensure the ability to monitor and measure
- Identify and/or secure resources (e.g., funding; staffing; and/or hardware/software) required to implement programs
- Review and approve workflows to ensure they are up-to-date and operationally efficient
- Provide guidance, expertise, and assistance to ensure operations are maintained effectively
Monitor and evaluate the Precision and Genetic Testing Management (GTM/PGTM) Program:
- Monitor operations against internal and/or external SLAs and performance guarantees (PGs)
- Ensure performance is tracked accurately utilizing internal tools and processes (e.g., dashboards, scorecards, reports)
- Establish operational performance measures to ensure that critical performance areas (productivity, service, quality, compliance, etc.) are being continuously monitored and improved
- Review relevant performance data from internal partners and review for accuracy
- Utilize data to facilitate operational reviews and analysis
- Review consolidated operational performance reports to determine operational effectiveness and make necessary changes, and identify opportunities for operational consolidation or expansion
- Incorporate operations performance metrics into strategic and business planning
- Analyze operational performance on relevant criteria (e.g., targeted financial metrics, quality indicators, performance guarantees, and/or incentives)
- Ensures that all operations activities are performed in a manner that is fully compliant with federal, state, and local laws and regulatory requirements
Build, maintain, and manage relationships with operational stakeholders:
- Provide standard performance and status reports to update internal leadership
- Develop action plans to address and resolve relevant concerns or regarding operational issues
- Conduct deep dive reviews to identify opportunities for continuous improvement
- Partner with relevant stakeholders to develop and/or review potential operational strategies, programs, and plans
Support, develop, and ensure compliance with operational policies and procedures:
- Demonstrate understanding of and adhere to relevant policies, procedures, and regulation
- Stay abreast of changes and/or updates in relevant policies, procedures, and regulation
- Ensure the right inputs are provided as policies and procedures get created and updated
- Ensure staff reference utilize the correct policies, guidelines, procedures, and regulations
Review, manage, and drive operational efficiency, quality, and financial performance:
- Immensely contribute to the financial planning process with estimation by highlighting dependencies, constraints, and impacts from a business standpoint
- Shape and implement continuous improvement in operational quality and financial performance (e.g., encourage participation in Six Sigma projects)
- Ensure external vendors adhere to business and contractual agreements
- Ensure that business continuity/emergency response plans are reviewed and tested regularly, up-to-date, and can be readily executed
- Demonstrate understanding of budgeting and forecasting tools, terminology, and processes
- Embrace and utilize Avalon culture to elevate and mentor resources
- Drive participation in Avalon’s employee experience survey
- Identify action plans in response to Avalon’s employee experience
- Ensure topics of inclusion and diversity are promptly and correctly addressed
Establish strategic service provider partnerships and manage outsourced services, maximizing the mix of in-house versus outsourced services to optimize cost of services:
- Selects, manage, and controls information technology service providers.
- Oversees the performance of the strategic outsourcer(s) providing and back-office services ensuring that the outsourcer(s) exceeds or meets its contractual obligations with established financial parameters.
Oversees information technology planning and policy-making committees, including the oversight of the corporate projects:
- Analyze business needs and solutions, devise strategies and facilitate stakeholder collaboration effectively and efficiently
- Define software quality attributes, external interfaces, constraints, and other non-functional requirements
- Oversees business system and related business process support, providing specialized expertise to ensure that business groups optimize the capabilities of business systems and the associated processes
- Responsible for data governance and management of all reporting across the operations organization
Vice President, Utilization Management and Quality Improvement:- Minimum Qualifications:
- At least 10 years of experience in managing the UM/PA process in a managed health care plan
- 7 years or more of managing a Quality Improvement plan in a managed care setting
- 5 years of managerial experience
- RN license - current, unrestricted
- Experience managing and optimizing department P&Ls
- Demonstrated staff management and development
- NCQA accreditation and reaccreditation experience
- Working knowledge of NCQA requirements and guidelines for utilization management, including denial/appeals processes and delegation oversight activities
- Knowledge of Medicare and Medicaid guidelines
- Experience at managing large scale initiatives and disciplined project management skills
- Progressive budget management experience
- Demonstrated ability to achieve results by leveraging resources with internal and external groups.
- Negotiation skills, strategic decision-making, problem solving and “sales” mentality. Must exhibit capability and skills to work in a cross-functional matrixed organization.
- Demonstrated success in building, developing, and motivating high performing teams and effectively growing an organization capable of supporting sustained membership growth.
- The ability to create and articulate an inspiring vision for the areas s/he is directly responsible for leading.
- The inclination to seek and analyze data from a variety of sources to support decisions and to align others with the organization's overall strategy.
- A leader who is viewed by others as having a high degree of integrity and forethought in his/her approach to making decisions; the ability to act in a transparent and consistent manner while always considering what is best for the organization.
- The ability to attract and recruit top talent, motivate the team, delegate effectively, celebrate diversity within the team, and manage performance; widely viewed as a strong developer of others.
Vice President, Utilization Management and Quality Improvement - Preferred Qualifications:
- Familiarity with ICD-10
- Exposure to genetic testing helpful
- DNP, BSN and/or MBA preferred
- Experience in an early-stage growth company