Director, Government Programs Clinical Operations

Enterprise HCM; Downers Grove (IL); Hybrid; USD 121,000 - 225,000; Full time

Job summary

HCSC is seeking a senior leader to direct change in processes and project integration for Government Programs Clinical Operations, spanning Medicare Advantage, Dual Eligibles, and Medicaid products.

You will optimize clinical reviews across Medical Management, Operations, Marketing/Sales and Medical, ensure accreditation and government regulatory compliance, and drive cost of care initiatives, quality analytics, and performance improvement.

Qualifications

• Bachelor degree OR clinical licensure (RN, LISW, LMSW, LPC, LCPC, LCSW) with current, unrestricted license.
• 4 years of management experience.
• 8 years in managed care operations, care management, quality of care or government health programs.
• Knowledge of Medicaid programs, claims payments and their impact on care management processes.
• Knowledge of State and Federal Medicaid regulations.
• Experience developing business requirements and reporting.
• Project management experience in medical processes.

Responsibilities

• Direct change in processes and integration of projects for Government Programs Clinical Operations.
• Optimize the clinical review process across Operations, Marketing/Sales and Medical departments.
• Ensure compliance with accreditation standards and government regulations.
• Lead cost of care initiatives and clinical management tools.
• Oversee triage and reporting of high dollar claims.
• Direct quality and performance analysis and customer service standards.
• Manage staff toward meeting goals and drive performance improvements.

Skills

Analytical skills

Verbal and written communication

Collaborative leadership

Travel readiness

Education

Bachelor's degree or clinical licensure

Job description

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.

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.

• Direct change in processes and integration of projects for Government Programs ClinicalOperations productsin 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 foroptimizingthe clinical review process across various departments including Operation, Marketing/Salesand 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 ofhigh dollarclaims.

• Direct quality analysis, performance analysis and customer service standards and metrics for GovernmentProgramsClinicalOperationsmedical management teams.

• Oversee performance guarantees andimplementingperformance 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, professionaldevelopmentand talent management.

• Maintain knowledge of Government Programs and Marketplace and change in products, services,processesand regulations.

• Maintain clinical licensure.

• Communicate and interact effectively and professionally with co-workers, management, customers, etc.

• Comply withHIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.

• Maintain complete confidentiality ofcompanybusiness.

• Maintain communication with managementregardingdevelopment within areas of assigned responsibilities and perform special projects asrequiredor requested.

Required Job Qualifications:

• Bachelordegree OR clinical licensure (RN, LISW, LMSW, LPC,LCPC, LCSW, with current, unrestricted clinical license to practice in state of operations.

• 4 years of management experience.

• 8 years of experience in one or more of the following fields:managedcare operations, care management, quality of care in clinical settings, or public/ government health sponsoredprograms..

• Knowledge of Medicaid programs claimspaymentsrules and their impact on care management processes.

• Knowledge of State and Federal regulations related to Medicaid programs.

• Experience developing business requirements and reporting.

• Project management experience in the planning, implementation, and review of medical processes.

• Knowledge of accreditation standards (i.e.;NCQA or EQRO).

• Knowledge of managed care principles and delivery systems.

• Knowledge or experience with quality improvement.

• Knowledge of healthcare/insurance industry, trends,regulationsand future market needs.

• Knowledge of managed care Customer Service processes, workflow, systems, reporting needs,trainingand quality.

• Collaborative leadership and team building skills including influencing,leadingand directing individuals in multiple functional areas.

• Analytical skills.

• Verbal and written communication skills including interpersonal skills and skills to develop andfacilitatepresentations to management and executives.

• PCproficiencywith Microsoft Suite applications

• Ability and willingness to travel, including overnight stays.

• Overseeing the annual budget and allocating resources for various projects and operational needs.

• Translating needs and initiatives into compelling business cases.

• Conducting cost-benefit analyses to justify investments and ensure ROI.

Preferred Job Qualifications:

• Master degree in Nursingor other Health Sciences.

• Certification in Case Management, Health CareAdministrationor Project Management.

• Clinical leadership and management experience focused in serving the pediatric special needs chronically ill, disabled, low income or frail population.

• Experience with MDCP and Texas State Special Needs Waivers.

• Texas Medicaid experience.

• Experience with new program implementations

• Bilingual, English/Spanish a plus.

INJLF

This is a hybrid role, in office 3 days/week based in Downers Grove, IL

Compensation: $121,200.00 - $225,200.00

Exact compensation may vary based on skills, experience, and location

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. We are a drug-free and smoke-free workplace. Employment may be contingent upon successful completion of drug screening in accordance with applicable law.