Communicate health care and health management industry methodologies used for health management programs; develop and execute plans and articulate vision.
Assure compliance with all external regulatory agencies related to the application of Medical Policy, and Appeals and Grievances processing.
Identify strategic directions/options for medical management and wellness related systems and propose options, including budget forecasts, system roadmaps and functionality.
Promote plan-wide understanding, communication, and coordination of population health management services
Manage use of corporate funds including budgeting, financial management, and reporting. Identify opportunities to achieve administrative efficiencies while maintaining service.
Collaborate with Data Science and Analytics to analyze utilization and identify opportunities to offer additional health management services to various customer segments, as well as, trend analysis and development of services for program advancement.
Analyze utilization, predictive modeling and clinical outcome data and provide ongoing analysis to appropriate executive members and committees of progress and priority issues.
Assist with the development and integration of new products as they relate to areas of responsibility. Health Management Operations
Provide leadership over all of the health management operations including health management programs, medical appeals and grievances, clinical training & auditing, medical policy, and medical claims review and ensure they meet the demographic and epidemiological needs of our members.
Provide leadership, strategic direction and management support for health management and population management programs that improve health outcomes, as well as support applicable health-plan accreditation standards and HEDIS measures.
Provide leadership, administrative and management support, strategic planning and overall direction of medical management, utilizing the principles of continuous process improvement to impact efficiency, effectiveness and outcomes.
Provide leadership and management in the support of the Health Management System including medical management workflow, predictive analytics software, and online precertification to support business growth and evolving strategies. Oversee and coordinate from a Business Owner perspective, the business requirements, end-to-end testing and user acceptance testing for processes involving your areas of responsibility.
Oversee operational activities related to mandated and voluntary levels of precertification / claim appeals and grievances.
Provide leadership, administrative and management support, strategic planning and overall direction of the intake, resolution and follow through for appeals and grievances.
Identify grievances and appeals for reporting to outside entities including the Arizona Department of Insurance.
Ensure all State, Federal , BCBS Association and Accreditation processing requirements are satisfied
Identify and analyze appeal and grievance patterns to identify opportunities for policy and benefit changes.
Oversee and negotiate vendor contracts for peer specialty reviews and external review of appeals. Manage the ongoing delegation of existing independent review organization (IRO) contracts.
Direct the clinical review of FEP subscriber reconsiderations, provider appeals, corrected claims and inquiries.
Manage the responses to Requests for Proposal (RFP) areas within related department
Coordinate and direct processing of Level 2 Grievance requests from third party administrators for Corporate Health Services (CHS) accounts.
Direct development of Medical Policy, technology implementation and publication of the MCG Hearst Health, Evidence Based Criteria, Medical Policies, as well as other guidelines pertinent to medical policy issues.
Oversee integration of coverage guidelines into the functions of each reviewing area within the Healthcare Quality Assurance and the various Business Segments across the company.
Aid in interpretation and implementation of State and Federal mandates relating to Plan Medical Policy and Member/Provider Appeal Rights.
Coordinate and assist in development of enhancements to existing systems or creations of new systems to improve efficiencies to processing.
Overall
Demonstrate quality management standards in daily problem solving within respective areas of responsibility leading by example and managing by fact.
Ensure new programs are integrated with all functional areas, including delegated entities, and responsive to competitive market demands.
Function as an SME for the clinical/medical management programs and presents the programs to clients and other external agencies both in-person and written.
Oversee day-to-day departmental administration by coaching and motivating managerial staff and departmental personnel to make maximum use of experience and skills.
Monitor quality performance measures, develop and maintain effective workflows, and seek to maximize system efficiencies.
Manage use of corporate funds including budgeting, financial management, and reporting. Identify opportunities to achieve administrative efficiencies while maintaining service.
Provide leadership for accreditation activities for areas of responsibility
Participate in strategic planning activities and contribute to departmental and cross-functional teams to achieve BCBSAZ goals. Support BCBSAZâs Core Value of maintaining a heritage of service, by volunteering with, serving on, and/or supporting multiple Boards of Directors within the community.
The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as needed to meet business requirements.
Maintain effective working relationships to ensure teamwork in achieving corporate goals.
Perform all other duties as assigned.
Employment Requirements
Required Work Experience
7 years of clinical experience
5 years of management experience
5 years of managed care, health services, health outcomes, or disease management experience, specifically in developing and implementing clinical programs
5 years of experience in developing short and long range strategic plans, forecasting, and budgeting Required Education
Masterâs degree in healthcare administration, business administration or related field Required Licenses
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN, LCSW, LPC, LISAC LMFT, Psy.D. or Ph.D. Required Certifications
N/A
Preferred Work Experience
10 years of management experience
10 years of clinical experience in a primary care field
10 years of managed care, health services, health outcomes, or disease management experience, specifically in developing and implementing clinical programs
5 years of experience in developing short and long range strategic plans, forecasting, and budgeting
Required Job Skills
Strong written and verbal communications.
Leadership capabilities with proven success
Critical thinking skills
Intermediate PC proficiency.
Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones.
Intermediate skill in word processing, spreadsheet, and database software.
Required Professional Competencies
Management skills in an operationally changing environment, with drive for results based on planned objectives.
Strong customer service skills.
Ability to influence business leaders and educate providers.
Advanced analytical and diagnostic skills dealing with issues that are often novel and not readily defined, lack known precedent or appear contradictory.
Interpersonal skills that allow for harmonious relationships with providers, members and coworkers .
Recognize strategic opportunities and use data to make timely and sound decisions.
Flexibility and willingness to adjust to shifting demands/priorities.
Ability and experience to assimilate multiple functions, services, projects and systems while maintaining existing systems and programs.
Expert knowledge of medical benefits management, quality initiatives, utilization review, managed care, contracting, negotiation and relationship building.
Conceptual and in-depth knowledge of the healthcare industry, including reform, competition, ancillary provider trends, and reimbursement models.
Strong ability to deal with abstract and concrete variables, apply principles of logical or scientific thinking to define problems, collect data, establish facts, and draw valid conclusions.
Strong knowledge of accreditation and accrediting bodies, including NCQA, and/or URAC.
Management skills in an operationally changing environment, with drive for results and success based on planned objectives.
Strong customer service skills.
Interpersonal skills that allow for harmonious relationships with providers, members and coworkers.
Recognize strategic opportunities and use data to make timely and sound decisions.
Flexibility and willingness to adjust to shifting demands/priorities.
Ability and experience to assimilate multiple new functions, services, projects and systems while maintaining existing systems and programs.
Excellent management skills as they relate to clerical and professional staff
Interpersonal skills that allow for harmonious relationships with providers, members and coworkers
Ability to successfully function in an environment characterized by risk taking, rapidly changing market conditions, strong competition and restructuring.
Proven knowledge of medical care delivery systems, quality management, benefit interpretation, provider relationships, and member services.
Comprehensive knowledge URAC, medical policy issues, and utilization management.
Strong understanding of the costs/quality challenges of todayâs health care environment.
Strong familiarity with the competition, market environment, healthcare economics, medical practices, managed care issues and provider/managed care systems and structures.
Proficiency in health economics analysis and understanding of statistics and health services research
Ability to identify key strategic performance measures for success
Required Leadership Experience and Competencies
High standard of performance while pursuing aggressive goals
The capacity, maturity, stature, and communication skills to assume a leadership role in a progressive, growing and changing organization
Principled leadership and sound business ethics
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