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Job Summary
This position is responsible for leading and managing the development, implementation, strategic day-to-day administration of managed care operations across clinical functions (Utilization Management, Quality Management, Project Oversight, Accreditation Readiness). Establish and lead teams in the execution of providing clinical operations support to clients to include oversight, processes, procedures and direction for managed care activities. Serve as champion of clinical operations to ensure that FEP clinical operations teams enhance the effectiveness, quality and client service objectives our clients expect. This position will assist in the development (along with business leaders and clinical leadership), processes that ensure the FEP clinical operations are compliant with internal and external requirements.
JOB REQUIREMENTS:
Required Licensed Registered Nurse (RN).
2 years of experience in a clinical/surgical setting.
Required 3 years of management experience.
Current experience in utilization management position to include pre-authorization, utilization review, concurrent review, discharge planning, and/or skilled nursing facility reviews.
Knowledge of medical management/nursing practices.
Analytical skills including presenting clinical/operational recommendations to executive management, Medical Directors, or external clients.
Problem solving skills.
Presentation skills including presenting information clearly, concisely, and in a positive manner to internal and external customers.
Knowledge of Utilization Management metrics, HEDIS and regulatory bodies such as NCQA and URAC.
Microsoft Office experience.
PREFERRED JOB REQUIREMENTS:
Registered Nurse (RN) with 2 years direct clinical experience to the consumer.
3 years of management experience in a managed health care setting.
Certification in UM, CM or DM.
Bachelor's or advanced degree in nursing or Healthcare field.
This is a Flex (Hybrid) role: 3 days in office 2 days remote
LI-LO1
LI-Hybrid
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Pay Transparency Statement:
At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards .
The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.
HCSC Employment Statement:
We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are 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
$92,700.00 - $167,500.00
Exact compensation may vary based on skills, experience, and location.
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For more than 80 years, HCSC has been dedicated to expanding access to high-quality, cost-effective health care and equipping our members with information and tools to make the best health care decisions for themselves and their families. As an industry leader, HCSC also has been helping to make the health care system work better for all Americans. To remain a leader, we offer compelling careers that encourage resourcefulness, strategic thought and empower you to make a difference in the lives of our members and their communities.
Today, with the industry at an important crossroad, HCSC is reimagining health care and looking for original thinkers who aren't afraid to make innovative contributions. We are an Equal Opportunity Employment employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Learn more about HCSC, our commitment to our members and the opportunity you'll have to improve health care delivery in an open, collaborative environment.
HCSC is committed to diversity in the workplace and to providing equal opportunity to employees and applicants.
If you are an individual with a disability or a disabled veteran and need an accommodation or assistance in either using the Careers website or completing the application process, you can call us at 1-866-977-7378 to request reasonable accommodations.
Please note that only requests for accommodations in the application process will be returned. All applications, including resumes, must be submitted through HCSC's Career website on-line application process. If you have general questions regarding the status of an existing application, navigate to "candidate home" to view your job submissions.
Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Montana, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas,
Divisions of Health Care Service Corporation, a Mutual Legal Reserve Company, and Independent Licensee of the Blue Cross and Blue Shield Association
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