Director, Commercial Care Management Operations

Job Description

What You'll Do (Job Responsibilities)

Strategy and Innovation

• Lead the development of operational strategies, policies, and innovative solutions for area(s) of clinical oversight; facilitating favorable medical expense, administrative pricing and/or efficiencies in the Clinical Operations and Innovations teams.
• Maintain awareness of trends, developments, and governmental regulations in managed health care organizations and product line(s) under leadership purview to drive recommendations on associated policy positions, new initiatives and/or existing program changes to improve the company's competitive position.
• Use competitive intelligence to guide, consult and drive strategic program and product development and management/enhancements

Operational Management

• Oversee the operational performance of multiple integrated PHM functions and teams including Case Management, Disease Management, Utilization Management, Medical Review and Policy, Coordination of Care, and/or Member outreach campaigns for different line(s) of business to ensure performance standards are met and in compliance with employer groups, FEP Directors' Office, and/or applicable state and federal regulations.
• Lead service initiatives/programs to facilitate and promote quality, cost effective outcomes and minimize the impact of fragmented health care delivery on the customers.
• Lead collaborations with internal and external customers and providers to deliver a fully integrated care delivery model and seamless member experience.
• Oversee the development and ongoing evaluation of performance and production metrics and goals, including process measures, outcomes measures and financial measures.
• Represent the organization with customers (i.e. employer groups, Blue Premier providers, physicians, CMS, DOI, FEP DO) as it relates to investigations or escalated/high profile cases; troubleshoot and provide guidance to staff to ensure resolutions and improved customer experience.

Programs/Vendor Management

• Lead, and/or support implementation of departmental, divisional, or corporate projects that impact all aspects of the service(s) under leadership purview.
• Lead the evaluation and management of vendor and partnership opportunities.
• Collaborate with technical areas to identify new technologies or improvements to systems to positively impact work and processes for areas under leadership purview.

Quality Management

• Drive an integrated continuous quality improvement and change process to assure high quality care, innovation, customer satisfaction and contribution to financial performance of the Program or Operations.

• Responsible for the oversight, compliance, and execution of all regulatory or accreditation activities and processes including the accuracy and compliance of the State, Federal, and other accrediting bodies (i.e. ERISA, DOI, NCQA, CMS).
• Serve as primary contact for compliance and regulatory body audits related to the services under leadership purview.

Communications

• Partner with divisional communications group to determine communication strategy for Clinical Operations programs, policies, and operations and ensure effective and accurate communications to all appropriate internal and external stakeholders
• Oversee or participate in internal committees relevant to work responsibilities; may represent the department through presentations and/or active participation in cross functional organizational committees.
• Represent the organization at external meetings with vendors, providers and customers as the clinical operations expert and decision maker when needed.

What You'll Bring (Hiring Requirements)

• Bachelor's degree and 10 years of relevant experience
• If no degree, at least 12 years of experience as stated above
• 5 years direct supervisory experience or leadership experience
• RN, PA, FNP or other APN certification. Other applicable licensure will be considered (LMSW, LCSW, LPC, LMFT). Must have valid NC license or multistate compact license
• Must have significant experience with management of population health, care management, clinical review or coding, or utilization management in a health care organization/system or health insurance

What You'll Get

• The opportunity to work at the cutting edge of health care delivery with a team that's deeply invested in the community

• Work-life balance, flexibility, and the autonomy to do great work

• Medical, dental, and vision coverage along with numerous health and wellness programs

• Parental leave and support plus adoption and surrogacy assistance

• Career development programs and tuition reimbursement for continued education

• 401k match including an annual company contribution

• Learn more

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs.Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.

*Based on annual corporate goal achievement and individual performance.

Skills