Director, Government Programs Clinical Operations & Impact

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

Job summary

Health Care Service Corporation (HCSC) seeks a leadership-level professional to direct changes and project integration for Government Programs Clinical Operations, spanning Medicare Advantage, Dual Eligibles, and Medicaid products. You will optimize clinical reviews across departments, ensure accreditation compliance, and drive cost of care initiatives with strong analytics.

The role requires 8+ years in related fields, strong Medicaid knowledge, and a collaborative leadership style.

Qualifications

• Bachelor degree OR clinical licensure (RN, LISW, LMSW, LPC, LCPC, LCSW) with current license to practice in state of operations.
• 4 years of management experience.
• 8 years in managed care, care management, quality or public/government 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 planning, implementation and review of medical processes.
• Knowledge of accreditation standards (NCQA).
• Knowledge of managed care principles and delivery systems.
• Knowledge of quality improvement and healthcare industry trends.
• Experience with MDCP and Texas State Special Needs Waivers is a plus.

Responsibilities

• Direct change in processes and integration of projects for Government Programs Clinical Operations across medical management.
• Optimize the clinical review process across Operations, Marketing/Sales and Medical departments.
• Ensure compliance with accreditation standards and government regulations.
• Direct and develop cost of care initiatives and clinical management tools.
• Oversee triage and reporting of high dollar claims.
• Direct quality and performance analytics and customer service metrics.
• Oversee performance guarantees and improvement plans.
• Manage staff and achieve goals with performance management and talent development.

Skills

Management experience

Analytical skills

Verbal & written comms

Microsoft Office

Education

Bachelor degree

Clinical licensure

Tools

Microsoft Suite

Job description

Health Care Service Corporation (HCSC) seeks a leadership-level professional to direct changes and project integration for Government Programs Clinical Operations, spanning Medicare Advantage, Dual Eligibles, and Medicaid products. You will optimize clinical reviews across departments, ensure accreditation compliance, and drive cost of care initiatives with strong analytics.

The role requires 8+ years in related fields, strong Medicaid knowledge, and a collaborative leadership style.