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VP Program Integrity

VP Program Integrity
New
Location: United States
Field: Executive
Requisition #: PS5300
Post Date: 2 hours ago
COMPANY OVERVIEW
Anthem is a Fortune 30 company and a leading health benefit company, with operating revenue of over $85 billion and over $60 billion in assets. Anthem serves over 40 million medical members, or one in every nine Americans. Together we will drive the future of health care . This is an exceptional opportunity to do innovative work that means more to you and those we serve.
Given Anthem?s scale, balance sheet, broad national reach and depth at the local market level, Anthem has established a new business unit called the Diversified Business Group (DBG). The Diversified Business Group is a solutions-oriented business unit within the Company that will support Anthem and other external clients in the pursuit of transforming healthcare. The Anthem Program Integrity team works to detect fraud, waste, and abuse through advanced analytics and strong enterprise governance in conjunction with DBG and all Anthem properties. Our objective is to work together to ensure proper payments are being made to legitimate providers for reasonable services provided to eligible members. Different from our competitors who choose to purchase and control providers, we prefer to partner with them and develop winning relationships for both sides.
POSITION OVERVIEW
We have taken a holistic view of Program Integrity and have consolidated functions and lines of business under a single Program Integrity leader. The Vice President, Program Integrity will be a key member of the DBG executive team, responsible for driving profitable growth of the business. This executive will oversee an organization of over 1600 associates and will be jointly responsible for the overall Program Integrity program including $4.5 Billion in payment recoveries and inappropriate payment avoidance. S/he will have direct operational oversight of Claims Edits, Reimbursement Policy, Clinical Programs (Complex Chart audits, Provider Education, and Prepayment Review), and the Special Investigations unit. In addition, this leader will also have oversight of Certified Professional Coders, Registered Nurses, and Medical Directors.
The VP, Program Integrity Clinical and Coding will drive new initiative development, execution, and assessment, working closely with Health Care Analytics to develop best-in-industry predictive analytics, optimize build vs buy strategies and identify opportunities for fraud, waste and abuse review. This leader will be accountable to all market, segment, and division leaders as well as state/federal authorities to deliver cost-of-care savings in a compliant and collaborative manner. S/he will collaborate with external stakeholders including state and federal agencies, law enforcement, BCBSA, trade organizations, and others to share findings and best practices as required and/or as appropriate.
The ideal candidate will have the ability to manage large transactional/operational teams; experience managing complex budget and financial commitments; and knowledge and experience in process improvement, technology assessment and enhancements and vendor management. Demonstrated success in leadership within a highly-matrixed organization, P&L or similarly significant financial accountability, and experience developing business cases for investments is strongly preferred.
Key to success in this role, the ideal candidate will:
+ Meet or exceed financial and operational objectives
+ Drive Program Integrity Innovation
+ Best in class fraud waste and abuse interventions and outcomes while collaborating with CA on innovative analytic approaches
+ Communication with and accountability to internal stakeholders and partners (market, segment, division leaders, provider contracting, IT, healthcare analytics) to optimize Program Integrity outcomes while minimizing stakeholder abrasion
+ Participate in externally facing activities with state/federal agencies, law enforcement, trade associations, etc.
+ Meet or exceed regulatory requirements; collaboratively develop nationally policies promoting program integrity
+ Identifying or creating synergies among various operating areas both within their direct oversight and internal partners
+ Enhanced cost of care savings, streamlining of activities
+ Have vendor management/oversight of key partners
CRITICAL SUCCESS FACTORS
_Communication and Influence_
+ Ask tough questions, challenge and engage leaders in conversation to ensure the right things happen for the business
+ Help leaders understand business implications of actions, influencing a change in direction as needed
+ Integrate key messages into all communications to ensure people understand how initiatives work together to support business goals
+ Has the executive presence to influence direction and inspire confidence with Anthem?s senior leaders _Visionary Thinking_
+ Establish strategies that create or sustain competitive advantage
+ Think broadly and long-term, recognizing the impact of decisions and actions on Anthem?s membership, business and key stakeholders over time _Focus your people_
+ Create an environment that enables and focuses people on the company?s mission and vision
+ Inspire superior performance by cultivating ownership and personal commitment to goals and objectives
+ Communicate strategic context to ensure people understand what we are doing and what drives them
+ Discontinue efforts not focused on critical business priorities _Executing for Results_
+ Hold oneself to the highest standards of accountability; has the ability to drive change while maintaining operating effectiveness; integrates and aligns efforts across functions; monitors results; tackles problems directly and delegates effectively. Direct reports: 6 indirect reports: 1600
+ Bachelor's degree in a related field (Master's preferred)
+ Minimum of 10 years in program healthcare and/or integrity-related field, and 5+ years? executive level experience or P&L responsibility. Preference for candidates who possess this experience in a similar role in a large, multi-market, multi-line of business organization.
+ CPC, RN, MD or relevant health certifications, with a time spent in a clinical, claims or program integrity field are preferred
+ Demonstrated successful leadership skills in program management, program execution, and people management
+ Ability to plan, organize, administer, and coordinate a variety of large and complex services, projects, and programs
+ Successful leadership and management experience building effective teams, managing cross functional teams, and continuous improvement/staff development programs
+ Demonstrated superior oral/written interpersonal communication, persuasion, and negotiation skills
+ Strategic thinking and demonstrated organizational leadership capabilities required
+ Key skills include analytical ability, innovation and creativity, teamwork and communications
+ Ability to successfully interface at all levels with the customer, industry, and corporate entities
Position located in one of Anthem?s nationwide offices, with expected heavy nationwide travel.
_Anthem, Inc. is ranked as one of America?s Most Admired Companies among health insurers by Fortune magazine and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran._


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