This position is responsible for developing and implementing Managed Care programs and strategies for Government Programs Clinical Operations; establishing cost-containment goals and objectives for the department along with policies, practices and procedures needed to meet those objectives; and for representing the company and division before outside customers and consultants.
* Registered Nurse (RN) with unrestricted, current license in the state of NM.
* Knowledge of medical terminology and procedures.
* 5 years of health insurance experience in Utilization Management, Case Management or Quality Management.
* 5 years of management experience.
* 2 years clinical nursing experience.
* Knowledge of accrediting body requirements (ie; NCQA or URAC).
* Experience with traditional Medicare, or Dual Eligible, or Medicaid claims payment rules and their impact on care management processes.
PREFERRED JOB REQUIREMENTS:
* Experience developing best practice approaches and innovations to address Medicaid member specific needs across a continuum of care.
* Certification in UM, CM or DM.
* Bachelor or advanced degree.
* Previous experience as a lead in a functional area, managing cross functional teams.
* Prior experience with NM Medicaid Programs.
Job ID: LEO-1024351