EXECUTIVE DIRECTOR, CLINICAL OPERATIONS
Company: HCSC
Location: Chicago
Posted on: October 19, 2024
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.
Please read the following job description thoroughly to ensure you
are the right fit for this role before applying.
Join HCSC and be part of a purpose-driven company that will invest
in your professional development. Job Summary This position is
responsible for directing the execution and delivery of specific
health care management programs; establishing cost-containment
goals, objectives, metrics, and return on investment (ROI) targets
for the health care management programs; ensuring compliance with
all certification and accreditation entities (DOI/URAC/NCQA) as
well as government (HIPAA/ERISA/department of labor) programs;
representing the company and the division before internal and
external customers; managing operations for medical care programs
to support effective utilization and support organizational
strategies. Oversee director level personnel and other upper
management in the operations of the health care programs. Ability
and willingness to travel, including overnight stays, as needed.
Job Responsibilities:
- Direct development of effective admission authorization/focus
review, concurrent review and medical determination intervention
techniques (including requests for appeal/IRO/reconsideration) for
the care management components and inquiries handled by the
Utilization Management/Provider Services Division (UM).
- Monitor department authorization and medical determination
activities and related turnaround times to ensure adherence to
Company service philosophies; review and modify activities as
needed to improve service and maximize cost-containment
efforts.
- Ensure establishment and coordination of an effective
communication process between Core UM and the (5) Rating Areas to
ensure good business rapport with network hospitals, other network
providers, and Limited Provider Networks in order to preserve and
enhance the effectiveness of the Medical Care Management (MCM)
Program.
- Establish cost-containment objectives and goals for UM
Department; plan and implement system and procedural changes to
achieve the objectives and goals; determine metrics to support and
monitor the goals on an ongoing basis.
- Provide for proper alignment and effective administration of
Medical Management requirements of hospital contracts; ensure that
contract terminology, interpretation, and pricing issues are
consistent with Company cost-containment objectives.
- Direct the development and implementation of effective Case and
Disease Management Programs to be coordinated as per Blue Card
requirements to result in Cost Benefits and improved patient
outcomes in order to impact Corporate, Employer Group, and MCM
goals and initiatives.
- Direct the development of metrics to ensure an effective MCM
program to monitor the effectiveness and quality of UM activities
and delegated review processes.
- Manage the development and implementation of additional
operating procedures and metrics required to maximize the
effectiveness and cost efficiency of the MCM Program.
- Direct the development and implementation of an Internal
Quality Monitoring Program (IQMP) to monitor and support the
operations of Core UM and the Rating Area staff to ensure
compliance with all regulatory requirements, i.e. TDI, DOL/ERISA,
NCQA, as well as both UM and CM URAC.
- Direct the development and implementation of a Training Program
to support all MCM staff throughout the State of Texas and for all
Product lines.
- Guide the establishment and/or maintenance of a favorable
rapport with internal Company area, other BCBS Plans, Employer
Groups, and other external sources to enhance Corporate
cost-containment efforts and preserve or improve the HCSC
image.
- Represent the Company and department before outside customers
and consultants.
- Apply relevant advances in cost-containment, claims processing,
and contract benefit interpretation to departmental efforts.
- Ensure preparation of annual budgets, which adhere to Corporate
guidelines.
- Ensure departmental compliance with HCSC policy to include
HIPAA, Corporate Integrity and Compliance Program, Diversity
Principles, Two-Way Communication, and the Performance Development
Rewards (PDR) initiatives.
- 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. Job Requirements:
- Clinical license (RN, LPC, LMSW, LISW) currently licensed with
3 years clinical nursing experience.
- 10 years of health insurance experience in Utilization
Management, Case Management or Quality Management.
- 9 years management experience including budget, strategy
development and execution of initiatives.
- Ability and experience in influencing, leading and directing
teams in multiple functional areas.
- Project management experience in the planning, implementation,
and controlling of Medical projects.
- Knowledge of various accreditation standards, i.e., NCQA, URAC,
etc.
- Knowledge of managed care principles and delivery systems.
- Familiar with claims payment rules and their impact on care
management processes.
- Knowledge of healthcare/insurance industry (external market)
current and future trends, to assess future market needs.
- Knowledge of service delivery processes, workflow, systems,
reporting needs, training and quality.
- Strong organizational skills and ability to function
cooperatively to achieve organizational goals and objectives.
- Effective communication, leadership, teambuilding, and
quantitative analysis skills.
- PC proficiency including various software programs i.e., Work,
Excel, PowerPoint, Access, etc.
- Ability and willingness to travel, including overnight stays,
as needed. Preferred Job Requirements:
- Certification in Case Management, Health Care Administration or
Project Management.
- Advanced degree in business, public health, administration or
other business field. *Please note: this is a hybrid role in our
Chicago office (300 E Randolph) 3 days/week* #LI-TR1 #LI-Hybrid
INNN Are you being referred to one of our roles? If so, ask your
connection at HCSC about our Employee Referral process! HCSC
Employment Statement: We are an Equal Opportunity Employment /
Affirmative Action employer dedicated to providing an inclusive
workplace where the unique differences of our employees are
welcomed, 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. Base Pay Range: $154,400.00 -
$286,600.00
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Keywords: HCSC, Elgin , EXECUTIVE DIRECTOR, CLINICAL OPERATIONS, Executive , Chicago, Illinois
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