Provide strategic and operational direction for the delivery of performance based medical management initiatives determined by organizational goals, ensuring consistency of services and compliance with regulatory and accreditation requirements.
Participate in the analysis of medical cost and utilization trends and develop improvement strategies.
Deploy HCCI Initiatives (Health Care Cost Initiatives).
Develop strategic plan to ensure sustainable long term competitive advantage and maintain position as an innovative organization that delivers results.
Prepare staffing models and updates as necessary, based on medical management market trends.
Oversee the development, implementation and oversight of new programs, processes, and best practices in response to medical, operational, service, accreditation and regulatory initiatives to drive the delivery of health care in a cost effective and quality manner.
Challenge current practices and adopt best practices.
Develop, implement and monitor performance improvement initiatives including operational performance metrics and audit processes to ensure highest quality of service to members.
Establish and integrate a streamlined comprehensive corporate care management program through system automation and process improvement.
Assess tools available to medical management team to assure that they are sufficient to meet operational goals.
Develop and manage the annual operating budget within financial objectives, ensuring both service and utilization goals are met.
BSN, RN preferred.
Master’s in Health Care Management or Administration preferred.
12 - 15 years of managed care experience required.
Progressive management experience required.
Industry level knowledge and understanding of regulations and best practices related to Care Management and Utilization Management required.
Working knowledge of regulations and coverage policy relating to an insureds’ benefits preferred
Experience in the development and implementation of analytics and metrics to measure programs’ success and evaluate for improvements to meet and exceed established goals for care delivery.
10+ years of managed care leadership experience required
6-10 years of leadership experience with increasing responsibility required
Health care administration preferred
Knowledge of NCQA, JCAHO and American Accreditation HealthCare Commission/URAC standards required
Knowledge of HEDIS and STARS requirements. Strong organizational skills
Excellent written, oral communication skills, including facilitation and presentation skills
Ability to work well in groups and independently
Knowledge of regulatory and accreditation requirements
Excellent conflict resolution skills
Proven track record for leading a progressive, efficient and cohesive medical management programs
Exceptional team building skills and proven ability to drive operational improvements through high-performing work teams
Thought leader with excellent negotiation, decision-making, and analytic skills
Excellent interpersonal, organizational, and leadership skills with the ability to coach, mentor and inspire staff to excel