VP Health Services / Health Services Director - Phoenix, AZ Hybrid

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The Vice President of Health Services (also known as the Health Services Director) is responsible for overseeing the care of a highly complex population eligible for both Arizona Medicaid and Medicare. This population includes members enrolled in four distinct health plans: Dual Special Needs Medicare, general Medicaid, individuals with intellectual and developmental disabilities, and elderly or physically disabled individuals requiring long-term care. The role requires comprehensive management of federal and Arizona state AHCCCS-mandated health service programs such as maternal child health, EPSDT, high-risk/high-needs care management, medical services, prior authorization, and special programs. Additionally, the position entails significant regulatory reporting and oversight duties.

The Health Services Director reports directly to the Chief Medical Officer (CMO) and serves as a key regulatory 'Key Staff' position required by AHCCCS and DDD contracts, referred to as the Medical Management Manager.

This role requires physical residency in Arizona and credentials as a Registered Nurse (RN), physician, or physician's assistant in good standing with their respective state licensing boards. The VP must have sufficient local staff with appropriate physical and behavioral health expertise to support whole-person health and ensure compliance with all AHCCCS MM contractual and policy requirements. Responsibilities include managing all Medical Management (MM) requirements outlined in AHCCCS and DDD policies, Arizona State regulations, rules, and contracts. This involves reviewing state policies and rules (e.g., AMPM; AdSS; AAC; CFRs; Health Plan Contracts) to ensure program compliance.

The Health Services Director provides leadership for functional areas such as High-Risk Care Management, Health Risk Assessments (HRAs), ED diversion/hold programs, Healthy First Steps (Maternal Child Health), Adult and Juvenile Judicial Reach-In Programs, among other state-mandated programs. The position oversees multiple Clinical Operational departments responsible for these regulatory programs, coordinating care and services to optimize resource utilization.

This leader supervises at least three direct reports who manage further teams, totaling approximately 70 health plan staff members. Responsibilities include ensuring adherence to compliance standards, maintaining processes that monitor member access to appropriate medical, behavioral health, dental, and pharmacy services. Additionally, this leader identifies and executes strategies to address business challenges across functions. The primary focus is on monitoring clinical activities for compliance while advising leadership on opportunities for improvement that impact medical expenses.

Primary Responsibilities:

• Health Services staff training, support, development and engagement
• State regulatory audits/operational reviews, including narratives and CAPs
• SME regarding state and federal legal and contractual regulations and requirements
• Administrative oversight of the monthly HQUM (Medical Management) regulatory committee meetings
• All regulatory chart of deliverable reports per contract
• RFP Development and subsequent program implementation
• Annual regulatory workplans and workplan evaluations, including ingoing data monitoring and analysis with data-driven interventions, including identifying, documenting and correcting over or under utilization of services
• Care Management programs
• Serve as the single point of contact, or designate a primary alternative point of contact, for home and out of State placements
• Chronic disease management and member educations
• Concurrent review, discharge planning and transitions of care
• Clinical and Operational Innovations
• Compliance and adherence
• NCQA accreditation activities and CMS DSNP Model of Care compliance
• All Health Services policies and procedures
• The development, adoption and application of appropriate, evidenced- based and community standard of care medical necessity criteria
• Precertification/Prior Authorization functions, processes, timelines and end-to-end monitoring
• In partnership with the Quality team, develop a work plan geared towards continuous quality improvement inclusive of clinical care management operations and performance
• Review, implementation and oversight of new programs/vendors
• Drive consistency amongst C&S clinical operations models and performance
• Collaborate with national affordability team to strategize and remediate complex care affordability projects within the market
• Primary liaison between the health plan (requirements) and all UHC/Optum intersegment national support functions, including requests for program changes, implementation, training, etc., balancing local customization with national scale and efficiency
• Accountable for ensuring clinical remediation plans are developed and successfully implemented for corrective action plans
• Monitor clinical data and identify trends
• Evaluate clinical processes and suggest revisions to increase productivity and efficient

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Registered Nurse (RN), physician, or physician's assistant in good standing with their respective state licensing agencies or boards
• 5+ years of experience as a care manager/utilization management helping individuals with integrated health needs
• Beginner or higher level of proficiency in Microsoft Office Suite including Word, Excel, Outlook, and PowerPoint
• Proven ability to prioritize, plan, and handle multiple tasks/demands simultaneously
• Proven excellent verbal and written communication skills
• Proven skilled learning and utilizing various systems, technology and platforms
• Demonstrated ability to translate strategic objectives into action plans
• Proven self-directed, independent thinking, flexibility to adapt and adjust to change
• Proven to lead and motivate teams to execute plans effectively

Preferred Qualifications:

• AZ Medicaid managed care experience to include healthcare operations, clinical services, network, products and benefits
• Experience in long-term care, home health, hospice, public health, skilled and assisted living treatment settings
• Experience working with individuals with multiple co-morbidities, special health care needs and complex medical conditions
• UHC/Optum affordability experience
• Solid understanding of federal and Arizona state AHCCCS regulations and requirements
• Proven commitment to delivering high-quality, patient-centered care and improving health outcomes for diverse populations
• Proven ability to identify complex problems and review of related information to develop and evaluate options and implement solutions
• Proven excellent people leader skills and at least five years' experience leading teams
• Proven leadership and organizational skills, with the ability to manage multiple programs and initiatives simultaneously

The salary range for this role is $124,500 to $239,400 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.