VP, Prospective Operations

The VP, Prospective Operations team is part of KF / HP-s Risk Adjustment organization. The VP will report to the SVP of Risk Adjustment. This individual will be responsible for overseeing all prospective operations teams, including operations teams, workflow design, and performance management. This individual will also lead a large team and coordinate across internal and external stakeholders, including analytics, provider groups, markets, vendors and health plan stakeholders. This individual is responsible for ensuring provider networks are informed of and aligned with end-to-end prospective operations and program goals. This includes fostering robust communication channels and collaborative relationships with the network to provide capacity support and maintain organizational alignment and regulatory compliance.

• Risk Stratification and Prospective Algorithms to Determine Patient Risk: Evaluate and implement analytical and predictive tools for improving identification of care gaps and promoting comprehensive care. This role will work collaboratively across the National Health Plan, Care Delivery, and the Permanente Medical Groups to align on both strategy and execution of that data to inform clinical, quality, and operational performance levers.
• Provider Capacity Support: Lead development and implementation of innovative strategies to engage providers for home visits and assessments, ensuring thorough capacity support 
• Reporting and Analytics Tracking: Collaborate with team managers to monitor prospective KPIs, generate reports and performance metrics, and use data to inform strategic decisions and program improvements.
• Provider Feedback: Ensure collaboration between internal teams and the provider network to collect feedback on prospective operations and engagement programs.
• Vendor Collaboration: Foster robust collaboration with vendors and alignment on vendor suspecting analytics across KF/HP markets
• Member Campaigns: Track member campaign performance and use vendor suspects to inform new initiatives for engaging member populations
• People Management: Oversee a team of 30 FTEs and demonstrate ability to manage multiple team priorities and capabilities simultaneously
• Program Improvement: Foster a culture of continuous improvement, encouraging team members to contribute ideas and solutions for enhancing operational processes.
• Regulatory Tracking: Monitor CMS and market-specific requirements to ensure program compliance with regulations.
• Risk Management and Timeline Oversight: Identify and mitigate risks within the team and with the vendor in a timely manner and ensure team is meeting timeline expectations for submissions
• Regulatory Compliance: This role is accountable for understanding all regulatory parameters around accurate and complete clinical coding and documentation in alignment with current regulations for all products, as well as understanding the strategic direction of the regulator and oversight bodies to proactively anticipate future changes.  This role will partner with Ethics & Compliance and/or Legal, as appropriate.
• Policy and Advocacy Strategy: This role will partner with government relations, trade associations, regulators, and other internal and external stakeholders to advocate for risk adjustment strategies that promote high quality, clinically appropriate care as well as financial sustainability and actuarially supported models for accurate reimbursement reflective of the costs associated with the populations we serve.
• Vendor Management: This role will selectively secure and manage vendors that meet stringent Kaiser Permanente clinical and compliance requirements to support our risk adjustment program. This will entail creating performance management and oversight protocols to ensure the highest standards of quality and compliance.
• Internal Stakeholder Management:  Develop an aligned risk adjustment system across all internal stakeholders, inclusive of our Permanente Medical Group partners, to ensure open communication, transparency of data, and the appropriate intersection and alignment of clinical, care delivery, quality, operational, product, financial/actuarial, and compliance stakeholders, among others.
• Team Leadership and Development: Ensuring the right skills, capabilities, and development opportunities exist for the risk adjustment team. Recruiting and retaining talent to the organization to support objectives and promote the highest quality risk adjustment team. This role will also need to integrate and oversee consultants or other team members who may provide technical, strategic, or other support to the risk adjustment team.

Qualifications:

• Minimum twelve (12) years of healthcare experience with the majority leading risk adjustment (or comparable) operations and strategy in a Health Plan or Integrated System capacity.

• Master-s degree in Healthcare Administration, Business, or a related field.

• N/A

• Leadership and Project Management: Demonstrated ability to lead end-to-end prospective operations, managing timelines, resources, and stakeholders effectively. Proven track record in overseeing complex projects and driving them to successful completion.
• Strategic Vision: Extensive experience in prospective operations, provider network strategy, and vendor strategy to formulate and implement executive strategies that align with organizational objectives.
• Communication Expertise: Strong communication skills, essential for frequent interactions with vendors, providers, and other relevant stakeholders. Ability to convey complex information clearly and persuasively.
• Provider Alignment: Substantial experience in provider and medical group communications, ensuring alignment and collaboration to support risk adjustment initiatives effectively.
• Industry Experience: Multiple years of experience in risk adjustment and prospective operations within the healthcare sector, with a proven record of leading teams to success.
• Regulatory Knowledge: Solid understanding of federal and state healthcare regulations, with the ability to navigate and apply these standards within prospective operations.

• Advanced degrees or relevant certifications are advantageous.