Position Purpose: Lead Medical Management process improvement initiatives to reduce medical costs, reduce administrative costs, and improve member quality.
- Assist Medical Management clinical leadership team to establish baseline and target metrics for key business/functional processes
- Develop and analyze reports across multiple systems to analyze key business drivers and trends in order to develop appropriate mitigation initiatives
- Collaborate and provide analytical support to Medical Management clinical leadership to facilitate the development, implementation, and evaluation of performance improvement initiatives.
- Develop processes to increase effectiveness and efficiency, while ensuring compliance with NCQA and contract requirements
- Lead end to end process evaluation from medical management processes to associated claims payment
- Develop and facilitate implementation of business processes to leverage technology to increase effectiveness and efficiency; integrating multiple systems to maximize outcomes
- Develop and implement a consistent methodology to evaluate pilots, processes, and programs
- Provide leadership and direction to Preauthorization Workforce Management team
Education/Experience: Bachelor's degree in Nursing, related field, or equivalent experience. Master’s degreepreferred. 7+ years of related medical management, operations, analysis, and managed care experience. Advanced knowledge of Excel and Access. Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.