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 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 operations.
*Knowledge of medical terminology and procedures.
*5 years of health insurance/health care 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.