We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability, or protected veteran status.
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 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.
*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 OR 8 years health care 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.
*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.