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 the office 3 days/week in Chicago HQ.
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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.
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.
Full-Time
Confirmed live in the last 24 hours
Health insurance provider in multiple states
$158.3k - $293.8k/yr
Senior, Expert
Chicago, IL, USA
Hybrid role, in the office 3 days/week in Chicago HQ.
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HCSC provides health insurance services across five states: Illinois, Montana, New Mexico, Oklahoma, and Texas. The company offers a variety of health insurance plans designed for individuals, families, and businesses, ensuring that different healthcare needs are met. HCSC generates revenue through premiums paid by its members and focuses on delivering quality care. The company also invests in health and wellness programs aimed at reducing healthcare costs and improving the health outcomes of its members. With nearly 100 years of experience, HCSC stands out from its competitors by emphasizing compassion and a commitment to innovation in the healthcare sector.
Company Size
N/A
Company Stage
N/A
Total Funding
$511.7M
Headquarters
Chicago, Illinois
Founded
1936
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Health Insurance
401(k) Retirement Plan
401(k) Company Match
Paid Vacation
Paid Holidays
Paid Parental Leave
Disability Insurance
Supplemental Life Insurance
Employee Assistance Program
Tuition Reimbursement
Professional Development Budget
Health Care Service Corporation invested in Pullman Tech Workshop with a grant to help continue its advanced workforce training program and purchase new supplies, including a table saw designed to lock immediately if a finger or body part contacts the blade.
Solera Health announced $40 million in new funding co-led by Health Care Service Corporation, Adams Street, Cobalt Ventures, and Horizon Mutual Holdings. The funding will expand Solera's HALO platform, including the HALO Cloud, to enhance digital health access and integration. John Santelli, former UHG CIO, becomes CEO. The investment supports Solera's mission to improve healthcare access and reduce costs. Recent achievements include product expansions and a strategic partnership with Aon.
New Mexico is the third state where HCSC has launched the expanded Maternal and Infant Health Initiative.
New Houston Office to Open in 2025CHICAGO, May 15, 2024 /PRNewswire/ -- Health Care Service Corporation is advancing its strategy to expand into neighborhoods where it can benefit from the skilled workforce in those communities and drive economic growth. The company has leased a 132,000 sq ft office building in Southwest Houston, Texas and will be creating opportunities to offer jobs in the local community.Health Care Service Corporation Is Expanding in Texas: New Houston Office to Open in 2025 Post this"We take a broad view of what it means to be healthy. Our commitment to expanding access to whole person health with compassion and innovation means that we consider the economic impact we make in our communities," said Opella Ernest, M.D., President, HCSC Markets. "As we grow our business, we are making intentional investments to create job opportunities that can benefit local residents and empower them to reinvest in the areas where they live."The new Houston location is at 8101 W. Sam Houston Parkway South. Buildout is expected to be completed as soon as January 2025.The new Houston site will be HCSC's latest expansion creating opportunities for individuals and businesses in the communities it serves