Director Government Programs Clinical Operations

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Job Summary

This position is responsible for directing change in processes and the integration of projects for government programs clinical operations to include 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. Ability and willingness to travel, including overnight stays.

*Please note, this is a HYBRID position which requires in-office hours 3 days a week at the respective office location.

Job Requirements:

• Registered Nurse (RN), with current, unrestricted license to practice in state of operations.

• 4 years of management experience.

• 8 years of health insurance experience in Utilization Management, Case Management or Quality Management.

• 2 years of 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’s 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.

• Medicaid experience.

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Pay Transparency Statement:

At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees.  Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards.

The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.

HCSC Employment Statement:

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are 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.

Base Pay Range

$118,800.00 - $220,800.00