Job Summary

This position is responsible for directing change in processes and the integration of projects for Government Programs Clinical Operations to include Medicare Advantage, Dual Eligibles, and Medicaid products across Medical Management organizations; optimizing the clinical review process across Operations, Marketing/Sales and Medical departments; ensuring Plan maintains compliance with accreditation standards and government regulations; directing and developing cost of care initiatives and clinical management tools ensuring that quality, expense and performance drivers are operational; overseeing triage and reporting of high dollar claims; directing quality analysis, performance analysis, and customer service standards and metrics of Medical Management teams; and overseeing performance guarantees and implementing performance improvement plans to address variances.

• Direct change in processes and integration of projects for Government Programs Clinical Operations products in medical management organizations across the enterprise. Execute on implementation and completion of projects to address strategies for Government Programs Clinical Operations products and services.

• Accountable for optimizing the clinical review process across various departments including Operation, Marketing/Sales and Medical.

• Ensure Plan maintains compliance with accreditation standards and government regulations.

• Direct and develop cost of care initiatives and clinical management tools ensuring that quality, expense and performance drives are operational.

• Oversee triage and reporting of high dollar claims.

• Direct quality analysis, performance analysis and customer service standards and metrics for Government Programs Clinical Operations medical management teams.

• Oversee performance guarantees and implementing performance improvement plans to address variances.

• Manage staff and the meeting/exceeding goals, address changes to ensure goals are met, includes but not limited to goal setting, performance management, pay administration, diversity, change management, professional development and talent management.

• Maintain knowledge of Government Programs and Marketplace and change in products, services, processes and regulations.

• Maintain clinical licensure.

• Communicate and interact effectively and professionally with co-workers, management, customers, etc.

• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.

• Maintain complete confidentiality of company business.

• Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

Required Job Qualifications:

• Bachelor degree OR clinical licensure (RN, LISW, LMSW, LPC, LCPC, LCSW, with current, unrestricted clinical license to practice in state of operations.

• 4 years of management experience.

• 8 years of experience in one or more of the following fields: managed care operations, care management, quality of care in clinical settings, or public/ government health sponsored programs..

• Knowledge of Medicaid programs claims payments rules and their impact on care management processes.

• Knowledge of State and Federal regulations related to Medicaid programs.

• Experience developing business requirements and reporting.

• Project management experience in the planning, implementation, and review of medical processes.

• Knowledge of accreditation standards (i.e.; NCQA or EQRO).

• Knowledge of managed care principles and delivery systems.

• Knowledge or experience with quality improvement.

• Knowledge of healthcare/insurance industry, trends, regulations and future market needs.

• Knowledge of managed care Customer Service processes, workflow, systems, reporting needs, training and quality.

• Collaborative leadership and team building skills including influencing, leading and directing individuals in multiple functional areas.

• Analytical skills.

• Verbal and written communication skills including interpersonal skills and skills to develop and facilitate presentations to management and executives.

• PC proficiency with Microsoft Suite applications

• Ability and willingness to travel, including overnight stays.

• Overseeing the annual budget and allocating resources for various projects and operational needs.

• Translating needs and initiatives into compelling business cases.

• Conducting cost-benefit analyses to justify investments and ensure ROI.

Preferred Job Qualifications:

• Master degree in Nursing or other Health Sciences.

• Certification in Case Management, Health Care Administration or Project Management.

• Clinical leadership and management experience focused in serving the pediatric special needs chronically ill, disabled, low income or frail population.

• Experience with MDCP and Texas State Special Needs Waivers.

• Texas Medicaid experience.

• Experience with new program implementations

• Bilingual, English/Spanish a plus.

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*This is a hybrid role, in office 3 days/week based in Downers Grove, IL

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Pay Transparency Statement:

At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards.

The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.

Flex employees are expected to be in the office a minimum of three days a week. Management will have discretion to modify an employee's weekly schedule for exigent circumstances.

Base Pay Range
$121,200.00 - $225,200.00

Exact compensation may vary based on skills, experience, and location.