Regional Vice President (Clark County, NV) at Alignment Healthcare USA, LLC in Henderson, Nevada

Job Description:

Overview of the Role:

Reporting to the SVP East Coast Region, the Regional Vice President/General Manager (RVP/GM) role is a critical leadership position responsible for driving market performance and achieving operational excellence in Nevada. The primary focus of this role is to hit key metrics, including achieving an 85% Medical Loss Ratio (MLR), ensuring MRA quality, driving a minimum of 30% net membership growth annually, and reaching 85% compliance in JSA and Annual Wellness Visits (AWVs).

The RVP/GM will manage end-to-end market performance, including overseeing P&L performance, market planning, and execution, while fostering effective relationships with key stakeholders across the healthcare ecosystem. To hit key metrics, the RVP/GM must drive collaboration and hold stakeholders accountable (internal and external). For example, leading the Health Economics team in designing and developing reporting to support Provider Contracting and Network Development, analysis of product line profitability, gross margin, and expansion market analytics.

Responsibilities:

P&L Management: Develop and execute the P&L strategy for Nevada and expansion markets, ensuring financial targets and MLR of 85% are met or exceeded. Develop and operationalize predictive KPI's to better forecast and manage responsible markets.
Operational Excellence: Drive performance in CAHPS, HEDIS, and HOS measures, aiming for 4 STARs or higher, and ensure efficient management of JSA's and AWV's to hit 85% completion rates.
Quality and Compliance: Lead initiatives to improve MRA quality and coding accuracy, maintaining compliance with CMS regulations, and hitting targets for quality programs.
Stakeholder Engagement: Build and maintain strong relationships with physician leaders, health systems, IPAs, and community partners to enhance market performance and strategic alignment.
Sales and Membership Growth: Direct local sales teams through market leaders to achieve a minimum of 30% net membership growth annually, aligned with market goals and regulatory requirements with a push with aligned quality partners.
Performance Management: Conduct quarterly business reviews through developed scorecards from provider operations, assess performance metrics, and implement corrective actions to drive improvements across key performance indicators. Work with Health Economics and Contracting teams to analyze contract rate trending impact and anomalies.
Market Strategy: Develop and refine business plans for Northern California and Nevada, incorporating regulatory impacts and changes to support sustainable plan performance.
Health Plan Oversight: Collaborate with Medical Officers and other departments to manage IPA, medical group, and hospital performance, with a focus on achieving budget and operating goals.
Utilization and Cost Management: Monitor regional performance, implement standardized performance scorecards, and address utilization and cost outliers to enhance overall market efficiency.
Network Management: Analyze, negotiate, and manage contracts with PCPs, specialists, and ancillary providers to optimize network performance and support plan objectives.
Innovation and Product Development: Partner with product teams to drive innovation, manage the annual bid process, and introduce new initiatives that enhance market competitiveness.
Medicaid and Dual Eligible Strategy: Develop and launch strategies to drive growth and retention in the dual eligible segment, including Medicare and Medicaid plans.
Compliance and Governance: Ensure adherence to all health plan compliance requirements in line with CMS regulations, and lead initiatives to improve patient satisfaction and operational compliance.
This role is pivotal in driving market success and delivering value to Alignment Healthcare members by managing financial, operational, and quality performance effectively and sustainably.

Supervisory Responsibilities:

Oversees assigned staff that support the network management needs of the markets. Responsibilities include recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees.

Required Skills and Experiences:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform essential functions.

Minimum Experience:

1. At least ten years of experience in financial/data analysis.
2. At least ten years of managerial experience
3. Education/Licensure:
4. BA/BS Degree in business or a relevant field is required; an MBA is preferred.

1. Knowledge of principles and practices of finance administration in accounting, budgeting, and auditing.
2. Understanding of CMS Premium payment methodologies to MA Health Plans. Understanding MMR documentation, premium payment calculations, Risk adjustment Factors (RAF), other premium adjustments, and file layout.
3. Understanding of CMS provider payment methodologies (DRG, RBRVS, etc.)
4. Understanding of operations, services, and activities within a Data Warehouse environment (Claim Data, Membership, Eligibility, and Revenue Data, etc.)
5. Understanding provider capitation contracts, developing capitation rates and contract carve-outs, and performing comparative analysis to Fee-for-Service.
6. Exposure and ability to use Actuarial studies related to IBNR.
7. Understanding of provider contracts for medical groups, independent physicians, and hospitals.
8. Understanding of payment methodologies for Hospitals (DRG, per diem, % of Billed, etc.), Physicians (RBRVS, FFS, Capitation, etc.), and other ancillary providers.
9. Develop new analyses and approaches to using data that allow fresh insights into the company's business.

1. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform essential functions.