Description
At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers.
Join HCSC and be part of a purpose-driven company that will invest in your professional development.
This position is responsible for directing the execution and delivery of specific health care management programs; establishing cost-containment goals, objectives, metrics, and return on investment (ROI) targets for the health care management programs; ensuring compliance with all certification and accreditation entities (DOI/URAC/NCQA) as well as government (HIPAA/ERISA/department of labor) programs; representing the company and the division before internal and external customers; managing operations for medical care programs to support effective utilization and support organizational strategies. Oversee director level personnel and other upper management in the operations of the health care programs. Ability and willingness to travel, including overnight stays, as needed.
Job Responsibilities:
1. Direct development of effective admission authorization/focus review, concurrent review and medical determination intervention techniques (including requests for appeal/IRO/reconsideration) for the care management components and inquiries handled by the Utilization Management/Provider Services Division (UM).
2. Monitor department authorization and medical determination activities and related turnaround times to ensure adherence to Company service philosophies; review and modify activities as needed to improve service and maximize cost-containment efforts.
3. Ensure establishment and coordination of an effective communication process between Core UM and the (5) Rating Areas to ensure good business rapport with network hospitals, other network providers, and Limited Provider Networks in order to preserve and enhance the effectiveness of the Medical Care Management (MCM) Program.
4. Establish cost-containment objectives and goals for UM Department; plan and implement system and procedural changes to achieve the objectives and goals; determine metrics to support and monitor the goals on an ongoing basis.
5. Provide for proper alignment and effective administration of Medical Management requirements of hospital contracts; ensure that contract terminology, interpretation, and pricing issues are consistent with Company cost-containment objectives.
6. Direct the development and implementation of effective Case and Disease Management Programs to be coordinated as per Blue Card requirements to result in Cost Benefits and improved patient outcomes in order to impact Corporate, Employer Group, and MCM goals and initiatives.
7. Direct the development of metrics to ensure an effective MCM program to monitor the effectiveness and quality of UM activities and delegated review processes.
8. Manage the development and implementation of additional operating procedures and metrics required to maximize the effectiveness and cost efficiency of the MCM Program.
9. Direct the development and implementation of an Internal Quality Monitoring Program (IQMP) to monitor and support the operations of Core UM and the Rating Area staff to ensure compliance with all regulatory requirements, i.e. TDI, DOL/ERISA, NCQA, as well as both UM and CM URAC.
10. Direct the development and implementation of a Training Program to support all MCM staff throughout the State of Texas and for all Product lines.
11. Guide the establishment and/or maintenance of a favorable rapport with internal Company area, other BCBS Plans, Employer Groups, and other external sources to enhance Corporate cost-containment efforts and preserve or improve the HCSC image.
12. Represent the Company and department before outside customers and consultants.
13. Apply relevant advances in cost-containment, claims processing, and contract benefit interpretation to departmental efforts.
14. Ensure preparation of annual budgets, which adhere to Corporate guidelines.
15. Ensure departmental compliance with HCSC policy to include HIPAA, Corporate Integrity and Compliance Program, Diversity Principles, Two-Way Communication, and the Performance Development Rewards (PDR) initiatives.
16. Communicate and interact effectively and professionally with co-workers, management, customers, etc.
17. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
18. Maintain complete confidentiality of company business.
19. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.
JOB REQUIREMENTS:
• Clinical license (RN, LPC, LMSW, LISW) currently licensed with 3 years clinical nursing experience.
* 10 years of health insurance experience in Utilization Management, Case Management or Quality Management.
* 9 years management experience including budget, strategy development and execution of initiatives.
* Ability and experience in influencing, leading and directing teams in multiple functional areas.
* Project management experience in the planning, implementation, and controlling of Medical projects.
* Knowledge of various accreditation standards, i.e., NCQA, URAC, etc.
* Knowledge of managed care principles and delivery systems.
* Familiar with claims payment rules and their impact on care management processes.
* Knowledge of healthcare/insurance industry (external market) current and future trends, to assess future market needs.
* Knowledge of service delivery processes, workflow, systems, reporting needs, training and quality.
* Strong organizational skills and ability to function cooperatively to achieve organizational goals and objectives.
* Effective communication, leadership, teambuilding, and quantitative analysis skills.
* PC proficiency including various software programs i.e., Work, Excel, PowerPoint, Access, etc.
* Ability and willingness to travel, including overnight stays, as needed.
PREFERRED JOB REQUIREMENTS:
* Certification in Case Management, Health Care Administration or Project Management.
* Advanced degree in business, public health, administration or other business field.
*Please note: this is a hybrid role in our Chicago office (300 E Randolph) 3 days/week*
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HCSC Employment Statement:
We are an Equal Opportunity Employment / Affirmative Action employer dedicated to providing an inclusive workplace where the unique differences of our employees are welcomed, respected, and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.
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