AVP, Clinical Process Improvement

What You Will Do:

• Establishes and leads the clinical process improvement strategy, standards and governance framework for VNS Health Plans, including methodologies for process assessment, design, documentation, implementation, measurement and continuous improvement.
• Partners with Health Plans Clinical and executive leadership to identify, prioritize and sequence high-impact clinical process improvement opportunities based on member impact, clinical and quality outcomes, regulatory risk, operational performance and business value.
• Establishes clear process ownership, decision rights, controls, accountabilities and performance expectations while appropriately addressing differences across products, populations and regulatory requirements.
• Leads end-to-end assessment and redesign of complex health plan clinical workflows; identifies variation, duplication, bottlenecks, handoff failures, administrative burden, compliance risk and opportunities to improve outcomes and efficiency.
• Defines future-state processes, workflows, business rules, roles, responsibilities, handoffs, controls and escalation pathways and establishes standards for clinical process documentation and version management.
• Leads implementation and operational readiness for redesigned clinical processes, including workflow, technology, staffing, training, communications, controls, measurement, change impacts and post-implementation stabilization.
• Partners with Technology and clinical leaders to translate operating requirements into technology-enabled workflows and identifies appropriate opportunities for automation, decision support and emerging technologies.
• Establishes mechanisms to monitor clinical process performance, identify variation and emerging issues, conduct root-cause analysis and implement sustainable corrective solutions.
• Defines measures and executive reporting for the clinical process improvement portfolio and quantifies operational, clinical, quality, member/provider experience and financial outcomes of improvement initiatives.
• Integrates CMS, New York State, accreditation and other applicable requirements into process design and partners with Compliance, Quality and Legal to mitigate operational and regulatory risk and support audit/readiness activities.
• Builds continuous-improvement capability across Health Plans clinical functions through repeatable methodologies, tools, coaching and knowledge transfer.
• Serves as a trusted advisor to Health Plans clinical leadership on process design, operating-model improvement and clinical transformation and presents recommendations, business cases, risks and outcomes to senior leadership.

• Leads complex cross-functional initiatives spanning Clinical, Operations, Quality, Compliance, Product, Technology, Analytics, Finance and other functions; creates alignment on future-state processes, accountabilities and implementation requirements.

• Develops change and adoption strategies for significant process changes and partners with operational leaders and Learning & Development to ensure new practices are understood, adopted and sustained.

• Provides leadership to assigned process-improvement resources and/or project teams, establishing priorities, standards and performance expectations; builds broader process-improvement capability within clinical teams.

• Participates in special projects and performs other duties as assigned

Licenses and Certifications:
Active clinical licensure, such as Registered Nurse (RN), preferred when relevant to the candidate's background and scope
Lean/Six Sigma or comparable process-improvement certification preferred; project or change-management certification preferred

Education:
Bachelor's Degree in Nursing, Healthcare Administration, Business Administration, Public Health, Industrial/Systems Engineering or a related discipline required

Master's Degree in Healthcare Administration, Business Administration, Public Health, Nursing or a related field preferred

Work Experience:

• Minimum 10 years of progressively responsible experience in healthcare, managed care, clinical operations, healthcare consulting, operational excellence or a related environment required
• Significant experience leading complex clinical process improvement, clinical transformation or operational-excellence initiatives in a health plan or managed-care environment required
• Demonstrated experience redesigning clinical processes across functions such as Utilization Management, Care Management, Population Health, Quality, clinical programs or related health plan operations required
• Demonstrated experience leading initiatives from current-state assessment and future-state design through implementation, adoption and measurement required
• Experience translating clinical and regulatory requirements into technology-enabled workflows and operating processes required
• Experience leading significant change and influencing leaders and teams across a complex, matrixed organization required
• Knowledge of Medicare, Medicaid, CMS and New York State managed-care requirements preferred