ABOUT THE JOB:
This position is responsible for assuring effective integration and efficient operation of the company's care delivery functions, thus contributing to achievement of corporate goals and fulfillment of the corporate mission and vision. As a member of the Leadership Team, this position is expected to a) contribute to corporate-wide strategic and business planning, priority setting and decision making, and b) represent and express the values of the organization.
SOME HIGHLIGHTED RESPONSIBILITIES:
Provides leadership for the Health Services department by a) clarifying performance expectations and assuring management accountability, b) delegating responsibility, authority and decision-making, as appropriate, c) contributing to development and implementation of strategies and tactics, d) using data, information, and analytical techniques to set priorities, make business decisions, and measure performance, e) promoting effective interdepartmental planning, analysis, and functioning, f) assuring compliance with all applicable laws, rules, regulations and contractual requirements, and g) mentoring and developing management staff.
Assures continuous improvement of medical management for all services under the umbrella of Health Management Services, inclusive of pre-certification of service requests, management of inpatient episodes of care, identification and management of at risk populations.
Assures that Health Management Services department operations have adequate human, financial and technological resources to function effectively and efficiently. In so doing, analyzes, negotiates and recommends acquisition of appropriate technologies, systems, equipment and vendor services.
Promotes the development, implementation and maintenance of operating policies and procedures within the Health Management Services department that maximize productivity, fulfill quality standards, and comply with all applicable laws, rules and regulations.
Directs the utilization of resources to perform review and determinations regarding medical service requests per Health Management Services Policy.
Directs the utilization of resources to perform care coordination and case management services including identification, assessment, intervention and evaluation of at risk populations.
Works collaboratively across the enterprise with other functional area leads to assure effective and efficient operations which meet the needs of membership, the provider community and the requirements of the regulators.
Serves as a member of the Leadership Team, sharing responsibility for, and contributing to, policy formulation, strategic direction, priority-setting, decision making, achievement of corporate goals, and overall leadership of the organization.
Assures regulatory compliance with all clinical and non-clinical operations within the Health Management Services Department.
Represents the company on appropriate local, state and national trade groups, government/industry work groups and committees, and similar external venues.
Minimum of six (6) years of managerial experience at the department director/manager level required. Evidence of progressive responsibility for multiple functions required.
M.D. or R.N. with a minimum of ten (10) years of relevant professional experience, preferably in a managed care plan or health care related enterprise strongly preferred.
Four-year Bachelor's degree or equivalent experience required
Current State of Texas RN or MD license required