Director Medicaid Programs- Clinical Operations, Utilization Management
Position: Director Medicaid Programs- Clinical Operations, Utilization Management (New Mexico)
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.
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 the 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. Ability and willingness to travel, including overnight stays.
Job Responsibilities:
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.Job Requirements:
Registered Nurse (RN), with current, unrestricted license to practice in state of operations.
4 year management experience.
8 years health insurance experience in Utilization Management, Case Management, or Quality Management.
2 years clinical nursing experience.
Knowledge of traditional Medicare, or Dual Eligible, or Medicaid claims payments rules and their impact on care management processes.
Experience developing business requirements and reporting.
Project management experience in the planning, implementation, and review of medical processes.
Knowledge of accreditation standards (ie; NCQA or URAC).
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 service delivery processes, workflow, systems, reporting needs, training, and quality.
Collaborative leadership and teambuilding 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 skills and experience to include Excel, PowerPoint, and Access.
Ability and willingness to travel, including overnight stays.Preferred
Job Requirements:
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 elderly, chronically ill, disabled, low income or frail population.
Medicare Advantage or Dual Eligible or Medicaid experience.
#LI-TR1
Please note this is a hybrid role, in the office 3 days/week in Albuquerque, NM
HCSC Employment Statement:
We are an Equal Opportunity Employment /
Apply Now
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.
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 the 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. Ability and willingness to travel, including overnight stays.
Job Responsibilities:
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.Job Requirements:
Registered Nurse (RN), with current, unrestricted license to practice in state of operations.
4 year management experience.
8 years health insurance experience in Utilization Management, Case Management, or Quality Management.
2 years clinical nursing experience.
Knowledge of traditional Medicare, or Dual Eligible, or Medicaid claims payments rules and their impact on care management processes.
Experience developing business requirements and reporting.
Project management experience in the planning, implementation, and review of medical processes.
Knowledge of accreditation standards (ie; NCQA or URAC).
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 service delivery processes, workflow, systems, reporting needs, training, and quality.
Collaborative leadership and teambuilding 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 skills and experience to include Excel, PowerPoint, and Access.
Ability and willingness to travel, including overnight stays.Preferred
Job Requirements:
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 elderly, chronically ill, disabled, low income or frail population.
Medicare Advantage or Dual Eligible or Medicaid experience.
#LI-TR1
Please note this is a hybrid role, in the office 3 days/week in Albuquerque, NM
HCSC Employment Statement:
We are an Equal Opportunity Employment /
Apply Now