Chief Health Services Officer

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• Provide strategic direction across HPSJ Health Services functions, consistent with contractual and regulatory requirements and organizational strategies
  
• Oversee Utilization Management, Case Management, Behavioral Health and Social Work, Quality Management, Quality Improvement and Health Equity, Health Education, HEDIS and NCQA, and Grievance and Appeals functions
  
• Supervise executive directors, directors, managers, and an executive assistant across Health Services
  
• Oversee operational objectives, business plans, tactics, and care program implementation
  
• Analyze care opportunities, issues, and trends; recommend and implement changes
  
• Collaborate with the Chief Medical Officer on Quality Improvement and Quality Management Programs
  
• Provide direction on medical claims review, grievances, appeals, and other Health Services issues
  
• Ensure consistent application of medical criteria in utilization management decisions
  
• Develop programs and educational opportunities for providers and members regarding Quality Improvement and Health Equity Transformation goals
  
• Coordinate Health Services and organizational teams with a focus on member care
  
• Lead health equity efforts to meet or exceed CMS, DHCS, DMHC, and NCQA requirements
  
• Develop policies, procedures, targeted interventions, and metrics to improve health equity and reduce health disparities
  
• Ensure required diversity, equity, and inclusion training for staff, subcontractors, and network providers
  
• Co-chair the Quality Improvement and Health Equity Transformation Committee and oversee the Health Equity Annual Report
  
• Represent HPSJ with county partners and participate in state and industry work groups including DHCS, DMHC, CHCF, NCQA, ACAP, and CAHP
  
• Prepare and oversee internal and external audits, regulatory reviews, corrective action plans, and quality reports
  
• Oversee quality concern trends and medical delivery system quality issues
  
• Develop and manage department budgets
  
• Oversee collection, storage, and retrieval of relevant data and information
  
• Maintain required records, documents, policies, and procedures
  
• Promote organizational values and a supportive workplace environment
  
• Hire, develop, retain, coach, and mentor Health Services leaders and staff
  

Requirements

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• Legal and valid work authorization, Green Card, or U.S. citizenship; the Health Plan does not sponsor visas
  
• Must reside in California
  
• Bachelor’s degree in nursing from an accredited nursing school
  
• At least six years in clinical operations in a healthcare setting
  
• At least six years in progressively responsible leadership positions in a healthcare setting
  
• Experience in an HMO or managed care setting
  
• Experience in utilization management, case management, or behavioral health for government-sponsored programs
  
• At least five years of experience developing and implementing Quality and Population Health Programs in a managed care setting in a senior leadership role
  
• At least three years of experience developing and/or implementing healthcare diversity initiatives addressing health equity and health disparities
  
• Certificate in Health Equity and Diversity, Health Disparities and Health Inequality, or another certification meeting California and/or federal requirements, or obtain within one year of hire
  
• Valid driver’s license
  
• Current unrestricted California RN license (if RN)
  
• Expert knowledge and proficient skills in administering clinical operations protocols
  
• Expert knowledge of Medi-Cal and Medicare regulatory requirements for utilization management, case management, and behavioral health
  
• Knowledge and ability to identify, implement, monitor, and analyze relevant metrics models
  
• In-depth knowledge of healthcare contract components and language
  
• In-depth knowledge of audit, control, and monitoring processes
  
• In-depth knowledge of medical management information systems and their interrelationships
  
• In-depth knowledge of health equity and diversity principles, concepts, and best practices
  
• Strong knowledge of medical policy benefits and exclusions
  
• Strategic planning and business plan development skills
  
• Very strong project management, facilitation, negotiation, conflict resolution, collaboration, interpersonal, communication, presentation, coaching, and counseling skills
  
• Strong budget development and management skills
  
• Customer service skills
  
• Intermediate mathematics skills, including basic algebra
  
• Intermediate skills in Word, Excel, and Outlook, including spreadsheets, formulas, tables, and graphs
  
• Ability to speak and be understood in English
  
• Ability to handle confidential information with discretion
  
• Preferred: strong clinical skills; knowledge of California or San Joaquin County healthcare issues; Medi-Cal and/or Medicare knowledge; managed care knowledge; and diversity, equity, and inclusion research and best-practice knowledge
  
• Preferred master’s degree in nursing, business, public health, or similar
  

Core Competencies

Demonstrates expertise in clinical operations, quality improvement, and health equity initiatives within managed care settings. xayajpt Proven ability to lead diverse teams, develop strategic plans, and ensure compliance with regulatory requirements.

Highest-signal resume keywords

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• Clinical Operations Management
  
• Quality Improvement Program Development
  
• Health Equity and Diversity Initiatives
  
• Utilization Management Expertise
  
• Leadership in Healthcare Settings
  

Hard Skills

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• Clinical Operations Protocols
  
• Utilization Management
  
• Quality and Population Health Programs
  
• Healthcare Contract Knowledge
  
• Budget Development and Management
  
• Intermediate Mathematics Skills
  
• Medical Management Information Systems
  
• Audit and Monitoring Processes
  
• Health Equity Principles
  
• Medi-Cal and Medicare Regulatory Knowledge
  

Soft Skills

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• Project Management
  
• Negotiation
  
• Conflict Resolution
  
• Interpersonal Communication
  
• Coaching and Counseling
  

Certifications & Qualifications

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• California RN License
  
• Certificate in Health Equity and Diversity
  

Industry Keywords

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• Managed Care
  
• HMO
  
• Health Services
  
• Grievance and Appeals
  
• Health Education
  
• HEDIS
  
• NCQA
  
• CMS
  
• DHCS
  
• DMHC
  

Tools & Technologies

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• Word
  
• Excel
  
• Outlook