Director of Operations, Care Management VBC

Hudson Regional Health Medical Group is seeking an exceptional Director of Operations to lead the outpatient and inpatient operations of its care management and value based care service lines across Northern New Jersey. This is a senior operations leadership position accountable for the full financial, operational, clinical support, and ancillary performance of the assigned programs, wherever that care is delivered.

Value based care is where HRHMG converts clinical quality into financial performance. This position owns the operating engine behind that conversion: the accountable care and clinically integrated network programs, the population health analytics, the quality and risk adjustment performance, the care management and remote monitoring programs, and the utilization and transitions of care work that connects the three Hudson Regional Health hospital campuses to the ambulatory enterprise.

The role is deliberately designed to be portable across value based programs and payer arrangements so that HRHMG can assign, combine, and reassign scope as the contract portfolio evolves. The successful candidate will be equally credible presenting shared savings performance to a payer, rebuilding a care manager caseload model, and standing on an inpatient unit resolving a transitions of care failure.

Scope of Responsibility

The scope of this position is fully integrated and spans both outpatient and inpatient settings. The Director of Operations is accountable for the financial, operational, clinical support, ancillary, and administrative performance of the assigned service lines wherever care is delivered: in HRHMG ambulatory practices and de novo sites, in hospital based outpatient departments, in procedural and diagnostic suites, and on the inpatient units, consult services, and hospital based programs of Hudson Regional Hospital (Secaucus), Bayonne University Hospital, and Hoboken University Hospital.

Service Lines in Scope

This position may be assigned to any single care management or value based care program, to any combination of programs, or to the entire value based portfolio, at any and all assigned locations. The listings below are illustrative of the current and planned HRHMG portfolio and are not exhaustive or limiting.

Current State (illustrative, not exhaustive)

• Accountable care organization and clinically integrated network participation, including shared savings and risk bearing arrangements.
• Pay for performance and pay for quality programs across commercial, Medicare, Medicare Advantage, and Medicaid payers.
• Medicare Advantage plan relationships, including quality, risk, utilization, and network performance obligations.
• Population health analytics, including risk stratification, attribution management, cohort analysis, predictive modeling, and performance reporting.
• Quality program operations, including Healthcare Effectiveness Data and Information Set measures, Star Ratings, Merit based Incentive Payment System performance, and payer specific quality programs.
• Risk adjustment operations, including hierarchical condition category and risk adjustment factor accuracy, suspect identification, prospective and retrospective review, and documentation and coding integrity.
• Care management programs, including Chronic Care Management, Principal Care Management, Transitional Care Management, Advanced Primary Care Management, complex case management, and disease management.
• Remote patient monitoring and remote therapeutic monitoring programs, including device logistics, enrollment, adherence, and clinical escalation.
• Behavioral health integration and collaborative care model operations, coordinated with the HRHMG behavioral health service line, the Partial Hospitalization Program and Intensive Outpatient Program, the Community Mental Health Centers, and the Giant Steps program.
• Annual Wellness Visit and preventive services programs, including outreach, scheduling, and completion.
• Transitions of care and utilization management across Hudson Regional Hospital in Secaucus, Bayonne University Hospital, and Hoboken University Hospital, including admission, discharge, and transfer notification, readmission reduction, emergency department utilization reduction, and post acute network coordination.
• Social determinants of health screening, community resource navigation, and health equity program operations.

Planned and Future State (illustrative, not exhaustive)

• Expansion into downside risk and full risk arrangements, including direct contracting and global capitation models.
• Medicare Advantage plan partnership expansion and evaluation of provider sponsored plan opportunity.
• Advanced Primary Care Management program build out at scale across the primary care portfolio.
• Post acute network narrowing and preferred provider network development, including skilled nursing, home health, and hospice partnership.
• Expansion of remote patient monitoring across chronic disease cohorts and post discharge populations.
• Integrated behavioral health and substance use disorder value based programming.
• Employer direct contracting and population based arrangements for Hudson Regional Health employees and external employers.
• Value based programs extended across newly acquired, infused, diffused, and de novo locations through the HRHMG MAIDD growth model, including the integration of newly acquired management services organization practices and their attributed populations.

Role Expectations and Key Responsibilities

The Director of Operations is expected to operate as a general manager of the assigned service lines, accountable for results rather than activity, and to lead through a disciplined daily management system.

Financial Leadership, Outpatient and Inpatient

• Own the profit and loss for every assigned care management and value based care program, including budget development, monthly variance analysis, forecasting, and written countermeasures for adverse variance.
• Own the financial performance of value based contracts within the assigned scope, including shared savings, quality earn out, pay for performance and pay for quality payments, care management program revenue, and risk adjusted payment accuracy.
• Own the operating economics of every fee for service care management program, including Chronic Care Management, Principal Care Management, Transitional Care Management, Advanced Primary Care Management, Behavioral Health Integration, Collaborative Care Model, Remote Patient Monitoring, Remote Therapeutic Monitoring, and Annual Wellness Visits, including enrollment, consent, time documentation, billing accuracy, and margin per enrolled patient.
• Model and monitor total cost of care, medical loss ratio, per member per month cost, and utilization trend for attributed populations, and translate those trends into operational countermeasures.
• Partner with Finance and Payer Contracting to build the financial analysis, performance forecasts, and settlement reconciliation for every assigned value based arrangement.
• Own the business case and vendor economics for any care management, analytics, remote monitoring, or population health vendor within the assigned scope.
• Quantify and report the contribution of value based performance to HRHMG and to the three hospital campuses, including avoided utilization and retained in network volume.

Operational Leadership, Outpatient and Inpatient

• Own the operating model for every assigned care management program, including staffing and caseload standards, licensure and skill mix, outreach and enrollment workflow, documentation standards, escalation pathways, and productivity expectations.
• Own enrollment growth and retention in every assigned program, including eligibility identification, outreach cadence, consent capture, and disenrollment root cause analysis.
• Own risk stratification and cohort assignment operations, ensuring the highest risk and highest opportunity patients receive the most intensive intervention.
• Own attribution management, including roster reconciliation, assignment accuracy, unassigned patient outreach, and correction of payer attribution error.
• Own transitions of care operations across all three hospital campuses, including admission, discharge, and transfer notification capture, inpatient care manager coordination, discharge planning participation, medication reconciliation support, post discharge outreach within the required interval, and follow up appointment scheduling.
• Own readmission reduction and emergency department utilization reduction programs, including high utilizer identification, targeted intervention, and closed loop measurement.
• Own post acute network operations, including skilled nursing, home health, hospice, and durable medical equipment partner performance, length of stay, and readmission performance.
• Own utilization management operations within the assigned scope, including prior authorization support, medical necessity documentation, and appeals coordination.
• Own remote patient monitoring and remote therapeutic monitoring operations, including device selection, logistics, enrollment, adherence monitoring, alert triage, clinical escalation, and billing compliance.
• Partner with the Patient Access Center on outreach campaigns, scheduling conversion, nurse triage, and after hours escalation for enrolled populations.
• Standardize operations across all assigned locations and programs so that the patient experience and the documentation standard are identical everywhere.
• Lead performance improvement using Lean, Six Sigma, or equivalent structured methodology, with documented structured problem solving for every material performance gap.
• Serve in the operational leadership structure for emergency management, downtime, and business continuity events affecting assigned programs and locations.

Clinical Operations, Quality, and Regulatory Compliance

• Partner in a dyad model with the value based care physician leadership, primary care and specialty physician leaders, and site Chief Medical Officers on clinical pathway design, care management protocols, and provider performance.
• Own the operational execution of quality performance, including Healthcare Effectiveness Data and Information Set measures, Star Ratings measures, Merit based Incentive Payment System measures, and payer specific quality programs, from gap identification through closure and validation.
• Own the operational execution of risk adjustment, including suspect generation, prospective visit scheduling, provider documentation support, retrospective review coordination, and compliant correction, with a strict prohibition on any practice that is not fully supported by the clinical record.
• Own measure abstraction, supplemental data submission, chart chase operations, and payer data exchange within the assigned scope.
• Own operational readiness for all applicable regulatory and program requirements, including Centers for Medicare and Medicaid Services program rules for accountable care and care management services, Medicare Advantage program requirements, National Committee for Quality Assurance standards, New Jersey Department of Health and Medicaid requirements, Occupational Safety and Health Administration standards, and Health Insurance Portability and Accountability Act privacy and security requirements.
• Ensure that all care management billing is supported by documented time, consent, medical necessity, and eligibility, and lead internal audit of that documentation on a defined cadence.
• Lead readiness for payer audits, program audits, risk adjustment data validation audits, and external reviews, and own the corrective action plan and its verification of effectiveness.
• Own patient and member experience performance for enrolled populations, including survey results, complaint resolution, and service recovery.
• Exercise immediate authority to suspend any workflow, program activity, or billing practice that presents a patient safety, compliance, or regulatory risk.

Ancillary Service Management

• Own operational coordination of the ancillary services required by care management and value based programs, including laboratory for quality measure closure, diagnostic imaging for screening measure completion, infusion and pharmacy coordination for medication adherence, therapy services for functional improvement, and durable medical equipment for home based care.
• Drive in network capture of ancillary, diagnostic, and post acute volume generated by care management activity, and measure and reduce leakage.
• Own the operations of mobile, in home, and point of care ancillary services deployed for gap closure, including in home screening, diagnostic collection, and assessment programs.
• Own turnaround time and closed loop result communication standards for any diagnostic service ordered through a care management program.
• Coordinate with hospital based laboratory, imaging, pharmacy, rehabilitation, and case management services to support transitions of care and readmission reduction at all three campuses.
• Own the operational and financial performance of remote monitoring device logistics, including procurement, distribution, retrieval, cleaning, inventory, and loss management.

People Leadership, Talent, and Culture

• Directly supervise Practice Administrators, Practice Managers, Service Line Managers, Supervisors, and Coordinators across all assigned locations, and lead through those managers rather than around them.
• Own workforce planning for the assigned service lines, including full time equivalent models, skill mix, coverage schedules, float and cross coverage pools, and reduction of agency, temporary, and overtime reliance.
• Partner with Human Resources on recruitment, onboarding, competency validation, compensation administration, engagement, retention, performance management, and progressive discipline.
• Establish and sustain a daily management system, including daily huddles, visual management boards, tiered escalation, and standard work for every leader in the assigned structure.
• Build the leadership bench. Maintain documented development plans for all direct reports and identify at least two internal successors for key positions.
• Model and enforce the HRHMG service standards, professional conduct expectations, and just culture principles at every assigned location.

Technology, Data, and Analytics

• Own operational optimization of eClinicalWorks in the ambulatory environment and coordinate with hospital leadership on MEDITECH dependent workflows affecting the assigned service lines.
• Define, build, and govern the operational and financial dashboards for the assigned service lines, and hold every manager accountable to a single agreed source of truth.
• Partner with the Patient Access Center on scheduling protocols, call handling, abandonment rate, conversion rate, referral routing, and after hours coverage for the assigned service lines.
• Support the enterprise telephony transition and any other system implementations affecting the assigned locations, including workflow design, training, go live support, and post implementation stabilization.
• Ensure data integrity, documentation of assumptions, and reproducibility of any operational or financial reporting produced by the assigned service lines.
• Identify and sponsor automation, digital access, self scheduling, and artificial intelligence enabled workflow opportunities that reduce administrative burden and improve access.

Growth, Integration, and Strategic Execution

• Support the HRHMG growth model, internally referred to as MAIDD: Mergers, Acquisitions, Infusions of providers and their patient panels into developing practices, Diffusions of providers out of capacity constrained practices into new or low volume sites, and De Novo site development.
• Conduct operational due diligence on acquisition and alignment targets, including staffing, space, volume, payer mix, systems, compliance posture, and integration cost.
• Own the operational integration plan and the first 180 days of post transaction performance for any assigned acquired, infused, diffused, or de novo location.
• Build and defend pro formas for new sites, new services, new provider additions, and service line expansion, in partnership with Finance.
• Support payer contracting and managed care strategy with accurate volume, capacity, cost, quality, and network adequacy inputs.
• Represent HRHMG professionally with providers, hospital leadership, payers, vendors, regulators, and the community.

Other Duties as Assigned

Performs any and all other job duties as assigned, at any and all assigned locations. This includes temporary or permanent assignment or reassignment to any HRHMG practice site, hospital campus, ambulatory location, administrative office, or affiliated location within the Hudson Regional Health network, and includes assuming operational coverage for additional service lines, departments, programs, projects, or leadership vacancies as directed by the Chief Executive Officer of HRHMG or designee.

This position description is not intended to be an exhaustive list of all duties, responsibilities, or qualifications associated with the role. Duties, responsibilities, reporting relationships, and assigned locations may be added, deleted, or modified at any time at the sole discretion of HRHMG.

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Minimum Qualifications

Candidates must meet every minimum qualification listed below to advance in the selection process.

Experience

• A minimum of five years of progressively responsible experience in a similar Director of Operations, Practice Administrator, Regional Director, Service Line Administrator, or equivalent senior operations leadership role within a medical group, health system, integrated delivery network, or multi site physician enterprise.
• Demonstrated leadership experience in care management, population health, value based care, or managed care operations.
• Demonstrated experience operating within at least two of the following: accountable care organization or clinically integrated network programs, Medicare Advantage arrangements, Medicaid managed care, commercial pay for performance or pay for quality arrangements, or risk bearing contracts.
• Demonstrated experience with quality program performance, including Healthcare Effectiveness Data and Information Set, Star Ratings, or Merit based Incentive Payment System.
• Demonstrated experience with risk adjustment operations and documentation integrity.
• Demonstrated experience operating billable care management programs, including enrollment, documentation, and compliant billing.
• Demonstrated experience with combined outpatient and inpatient or hospital based operational accountability.
• Demonstrated profit and loss accountability, including budget development, variance analysis, and delivery of measurable financial improvement.
• Demonstrated experience leading through subordinate managers across more than one physical location.

Education

• Bachelor degree from an accredited institution in Healthcare Administration, Business Administration, Public Health, Nursing, Health Informatics, Finance, or a closely related field is required.
• Master degree (MHA, MBA, MPH, MSN, MSHA, or equivalent) is strongly preferred and may substitute for one year of the minimum experience requirement.
• Active clinical licensure, where held, must be current and in good standing in the State of New Jersey or in a compact state recognized by New Jersey.

Other Requirements

• Valid driver license, reliable transportation, and the ability to travel routinely among all assigned HRHMG and Hudson Regional Health locations across the assigned Northern New Jersey counties.
• Ability to satisfy all pre employment and ongoing requirements, including background check, drug screen, health clearance, immunization compliance, and federal exclusion screening.
• Unrestricted authorization to work in the United States. HRHMG does not guarantee visa sponsorship for this position.

Preferred Qualifications

• Master degree in Healthcare Administration, Business Administration, Public Health, Nursing, Health Informatics, or a related field.
• Active Registered Nurse licensure in the State of New Jersey or a recognized compact state.
• Certification in Case Management, Managed Care, Professional Coding, Risk Adjustment Coding, Lean Six Sigma, or Project Management.
• Direct experience with Medicare Shared Savings Program, ACO REACH, Primary Care First, or comparable federal value based programs.
• Experience with risk adjustment data validation audit preparation and response.
• Experience building or scaling a remote patient monitoring program.
• Experience with post acute network development and skilled nursing or home health partner management.
• Experience with payer contract negotiation support, settlement reconciliation, and performance dispute resolution.
• Working knowledge of eClinicalWorks, MEDITECH, health information exchange, and population health analytics platforms.
• Experience with New Jersey Medicaid, New Jersey health information exchange participation, and Northern New Jersey payer market dynamics.

What We Offer

• Competitive compensation based on experience and qualifications: When determining the compensation, several factors may be considered including, years of relevant experience, credentials, union contracts, education, and internal equity.
• Comprehensive health, dental, and vision insurance
• 401K, Retirement savings plan
• Generous Paid Time Off (PTO) and paid holidays
• Tuition Reimbursement
• Opportunities for professional growth, development, and continuing education
• Employee wellness programs and resources

Influenza Vaccinations are a requirement for employment. If you are not currently vaccinated you will be required to receive the vaccination prior to hire date, during the influenza season, if you are offered employment, unless you request and receive an approved medical exemption.

We are an Equal Opportunity Employer encouraging diversity in the workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, gender, age, religion, disability, sexual orientation, veteran status, marital status, or any other characteristic protected by law.