HCMS Director

Elevance Health; Hanover (MD); Hybrid; USD 115,000 - 173,000; Full time

Job summary

Elevance Health in Maryland seeks a Director of Health Care Management to lead utilization and care management across diverse member populations. The role focuses on delivering essential services, optimizing cost and quality, and ensuring program compliance in a dynamic health plan environment.

The role requires strong leadership, collaboration with internal and external stakeholders, and extensive experience in case management and clinical operations.

Qualifications

• BA/BS degree in a health care field and at least 8 years of clinical experience including prior management experience or an equivalent background.
• Experience in clinical operations and care management.
• Strong knowledge of utilization management and quality improvement processes.

Responsibilities

• Implements and manages health care management, utilization, cost, and quality objectives.
• Ensures program compliance and identifies opportunities to improve customer service and quality outcomes.
• Oversees development and execution of medical and case management policies, procedures, and guidelines.
• Assists in developing clinical management guidelines.
• Ensures medical management activities are contracted, reviewed and reported.
• Supports quality initiatives including clinical indicators reporting and HEDIS reporting.

Skills

Case management

Clinical operations

Utilization management

Stakeholder collaboration

Quality reporting

Education

BA/BS in health care

Tools

HEDIS reporting

NCQA reporting

Job description

Location: Maryland This role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The HCMS Director is responsible for managing the utilization or care management process for one or more member product populations of Physical Health and/or Behavioral Health of varying medical complexity ensuring the delivery of essential services that address the total healthcare needs of members.

How will you make an impact:

• Implements and manages health care management, utilization, cost, and quality objectives.
• Ensures program compliance and identifies opportunities to improve the customer service and quality outcomes.
• Oversees the development and execution of medical and case management policies, procedures, and guidelines.
• Assists in developing clinical management guidelines.
• Ensures medical management activities are contracted, reviewed and reported.
• Supports quality initiatives and activities including clinical indicators reporting, focus studies, and HEDIS reporting.
• Serves as liaison to state regulatory agencies. Drives direction of the plan related to cost of care and other plan directives.
• Ensures program compliance and identifies opportunities to improve the consumer experience and quality outcomes.
• Requires a BA/BS degree in a health care field and a minimum of 8 years clinical experience including prior management experience; or any combination of education and experience which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

• LICSW, LCSW, LPC, or, Psychiatric RN strongly preferred.
• Advanced knowledge of Maryland Medicaid strongly preferred.
• 5+ years case management and clinical operations experience strongly preferred.
• Extensive utilization management review experience strongly preferred.
• Ability to partner and collaborate with key external and internal stakeholders strongly preferred.
• National Committee for Quality Assurance (NCQA) accreditation and HEDIS reporting experience preferred.

For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $115,080.00 - $172,620.00 USD Annual

Locations: Maryland

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

*If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties, principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact [e-mail] assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act