Job Summary:The ED, Medicare Duals/SNP Programs will develop and execute the Duals and DSNP (Dual Special Needs Program) development plan across the Enterprise, as KP increasingly serves individuals who are eligible for both Medicare and Medicaid. This plan will include a single, enterprise approach to Duals governance, care coordination, social health, and product strategy for KP-s Dual eligible members. This leader will establish a dedicated Dual Eligibles Team that focuses on required and necessary Health Plan Administration, social needs, and care coordination responsibilities. Health plans are aggressively looking to grow in Duals and DSNPs where revenue streams from CMS (Centers for Medicare & Medicaid Services) are higher than those from Medicare alone. In the marketplace across KP-s footprint, the market for Dual Eligible enrollment has grown at 3% CAGR (Compound Annual Growth Rate) since 2017. DSNP enrollment has grown 11% CAGR over the same period. Comparatively, the commercial market has been relatively flat. With only 10% market share in our footprint currently, KP is well positioned for growth. Policy makers and regulators have increasingly focused on expenses and have pushed for better care coordination. As such, KP-s integrated care delivery model positions the company well over its competitors. This position will be a critical accountable leader to deliver that growth. This role is accountable for establishing and leading a multi-year, growth strategy for the Duals business across both the Medicare and Medicaid businesses. This position serves as an integral member of the Medicare Advantage and Medicaid teams and reports to the SVP, Government Programs. The selected individual will demonstrate experience in leadership, strategic planning and organizational, operational, and technical skills, and customer relationship management. This individual directs the efforts to demonstrate strategic leadership, produce high quality outcomes, growth and retention, financial performance, and operational execution to serve vulnerable populations. This role is expected to lead cross functional teams within the National Health Plan and partner with both Regional teams and Permanente Medical Groups to deliver on revenue, membership growth, operating income objectives, develop key care delivery relationships, establish an influential relationship with the State in partnership with Medicaid leadership, direct and effectively develop strategic goals into specific business plans, and create a successful, collaborative team to achieve these goals. This executive will manage a matrix organization of product, population health, model of care management, compliance, and regulatory teams to develop Duals products, enhancements, and ongoing management processes. Essential Responsibilities:
Own strategic responsibility for Duals product, competitively positioning the product through an understanding of both the regional market and Federal and State regulatory landscape. Through these insights, produce a competitive product that aligns with regional objectives and delivery system for growth, quality, and margin.
Analyze and recommend specific product strategies for Dually Eligible beneficiaries based on population and segmentation analysis to include Dual Special Needs Plans (DSNP), Chronic Special Needs Plans (CSNPs), Low Income Subsidy Plans (LIS), and Institutional Special Needs Plans (ISNP), where appropriate for the market, and that align around broader strategic, growth, quality, and margin objectives.
This role will be accountable for ensuring an optimal CMS bid strategy while accounting for all State regulatory, policy, and operational parameters, inclusive of an intimate understanding of how CMS payment models and risk adjustment program parameters impact our strategic, financial, and operational approach.
This role will partner with KP-s pharmacy organization to align formulary strategies and operational parameters with optimal product design and performance.
Design the marketing and distribution channel strategies to grow from both external channels as well as optimize internal conversion strategies leveraging Duals specific strategies and partnership strategies (e.g., brokers, community partnerships, provider relationships, etc.).Own the comprehensive Model of Care (MOC) for Dually Eligible members from a National Health Plan perspective, working in alignment with delegated stakeholders and provider partners. Design and execute a MOC that will deliver differentiated clinical, quality, affordability, and equity outcomes for Dually Eligible beneficiaries generally, and sub-segmented populations specifically - inclusive of national preparedness for Managed Long-Term Services and Supports (MLTSS) or other State initiatives in the pipeline for regional markets. This role will work effectively and collaboratively with internal care delivery stakeholders, other National Health Plan stakeholders and external delivery and vendor partners.
This role will create and lead the Health Equity Index strategy to support optimal growth and quality alignment with CMS Health Equity Index parameters and optimize Star ratings, to include contract and PBP optimization, product design strategies, care coordination, and alignment with social health stakeholders, among others, to drive both penetration of Duals and top-tier performance as defined by CMS.
Own and design the comprehensive member journey starting with enrollment and onboarding, and including but not limited to, NHP and market-based engagement strategies, care management assignment and coordination, population health management programs, and delivery system design and navigation.
This role will be accountable for understanding current and prospective State policies related to Duals, and the corresponding implications for product design, operating model alignment, regulatory compliance, and financial and operational coordination of benefits and payment policy execution.
Through competitive intelligence, market research, and data driven analytics, identify opportunities for innovation in product design, network configuration, strategic partnerships, service improvements, and affordability opportunities.
Serves as the Duals thought leader and policy expert within Government Programs, providing cross functional guidance to optimize performance of the product internally, and supporting advocacy efforts externally in partnership with government relations.
This role works with Medicaid and Medicare teams, and other internal and external stakeholders, to ensure program requirements are met from RFP/ application through implementation. This role will participate in the development and review of all regulatory submissions, policy feedback, and other materials designated as relating to SNP products.
This role will be responsible for ensuring all coordination of benefit, integration and data sharing requirements, and crossover claim policies are closely tracked and adhered to for both compliance and margin optimization.
Ensure oversight and compliance of delegated entities for meeting the regulatory, quality, and margin expectations for the product.
Basic Qualifications:
Experience
Minimum eight (8) years leadership experience in health benefits marketing, sales, business development, account management, distribution channels, operations and administration, including at least five (5) years Government programs health plan experience in Duals, Medicare Advantage, and Medicaid experience.
Education
Bachelor-s degree in business administration, public health, or related field.
License, Certification, Registration
N/A
Additional Requirements:
Finance and/or actuarial experience preferred (as needed for bid development and strategy).
Preferred Qualifications:
Product design, P&L accountability for overall product performance preferred.
Experience working with network and care delivery partnerships preferred.
Master-s degree in business, public health, preferred.
COMPANY: KAISERTITLE: Executive Director, Duals/SNP Programs Line of BusinessLOCATION: Oakland, CaliforniaREQNUMBER: 1320296External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.