Hybrid Director, Government Programs Clinical Operations

Health Care Service Corp.; Downers Grove (IL); Hybrid; USD 121,000 - 225,000; Full time

Job summary

Health Care Service Corporation in Downers Grove, IL seeks an experienced leader to direct change in processes and integrate projects for Government Programs Clinical Operations across medical management. You will optimize the clinical review process, ensure regulatory compliance, and guide cost of care initiatives while overseeing triage and high-dollar claims.

The role demands extensive experience in managed care, accreditation standards, and strong leadership.

Qualifications

• Bachelor degree 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 managed care operations, care management, quality of care in clinical settings, or public/government health sponsored programs.
• Knowledge of Medicaid programs claims payments rules 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 planning, implementation, and review of medical processes.
• Knowledge of accreditation standards (NCQA or EQRO).
• Knowledge of managed care principles and delivery systems.
• Knowledge of quality improvement.
• Knowledge of healthcare/insurance industry, trends, regulations and future market needs.
• Knowledge of managed care Customer Service processes, workflow, systems, reporting needs, training and quality.
• Collaborative leadership and team building 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 proficiency with 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.

Responsibilities

• Direct change in processes and integration of projects for Government Programs Clinical Operations products in 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 for optimizing the clinical review process across various departments including Operation, Marketing/Sales and 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 of high dollar claims.
• Direct quality analysis, performance analysis and customer service standards and metrics for Government Programs Clinical Operations medical management teams.
• Oversee performance guarantees and implementing performance 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, professional development and talent management.
• Maintain knowledge of Government Programs and Marketplace and change in products, services, processes and regulations.
• Maintain clinical licensure.
• Communicate and interact effectively and professionally with co-workers, management, customers, etc.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
• Maintain complete confidentiality of company business.
• Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

Skills

Leadership

Healthcare operations

Project management

Analytical skills

Communication skills

HIPAA compliance

Budget management

Regulatory knowledge

Education

Bachelor degree OR clinical licensure

Job description

Health Care Service Corporation in Downers Grove, IL seeks an experienced leader to direct change in processes and integrate projects for Government Programs Clinical Operations across medical management. You will optimize the clinical review process, ensure regulatory compliance, and guide cost of care initiatives while overseeing triage and high-dollar claims.

The role demands extensive experience in managed care, accreditation standards, and strong leadership.