JOB SUMMARY Responsible for oversight of all Health Plan Care Coordination and Quality Improvement activities that ensure compliance with National Committee for Quality Assurance (NCQA) accreditation and other regulatory standards. Works under the direction of the Chief Medical Officer to collaborate with Medical Directors and develop a health services strategy consistent with creating positive medical outcomes and efficient utilization management operations. Established overall annual goals for the health services team.
ESSENTIAL FUNCTIONS OF THE ROLE Lead a team of quality improvement, clinical analytics, utilization management, and casement management professionals.
Ultimately responsible for ensuring Health Plan services are provided in accordance with state/federal regulations and NCQA standards.
Champions health care improvement initiatives internally and externally.
Collaborate with other members of Chief Medical Officer's leadership team on strategic planning for existing and expanding business; recommend changes in program content in concurrence with changing markets and technologies.
Assure plan conformance with legal and regulatory requirements; support NCQA qualification activities, including site visits and response to accrediting and regulatory agency feedback.
Participate in risk management, claims administration, pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, site visit review coordination, triage, nutrition service review, provider orientation, credentialing, profiling, etc.
Develop response to quality improvement and outcomes studies to ensure an environment providing opportunity for the best possible medical outcomes, in compliance with regulating bodies.
Monitor member and provider satisfaction survey results and implements changes as needed to increase satisfaction and assure that satisfactory relationships are maintained between network and plan participants.
Participate on various Health Plan committees, such as the Quality Management subcommittees on Peer Review or Credentialing.
Promote wellness and ensure programs of prevention, education and outreach to members and providers consistent with company's mission, vision, and values.
Contribute to the development of strategic planning for existing and expanding business; recommend changes in program content in concurrence with changing markets and technologies.
Participate in key marketing activities and presentations, as necessary, to assist the marketing effort
Performs other position appropriate duties as required in a competent, professional, and courteous manner as directed by management.
KEY SUCCESS FACTORS Must have at least 7 years health plan or case management experience, with at least 3 years being in a management capacity.
Strong leadership and communication skills to effectively operate in the complex environment of an integrated health system.
Knowledge of quality improvement and UM practices in a managed care environment.
Knowledge of regulatory and accreditation agencies and requirements.
Demonstrated ability to manage multiple priorities and deadlines in an expedient and decisive manner.
Demonstrated ability to manage difficult peer situations arising from medical care review.
Appreciation of cultural diversity and sensitivity towards target population.
Strong expertise on the application of technology to Health Plans, to include Care Management Platforms.
Our competitive benefits package includes the following - Immediate eligibility for health and welfare benefits - 401(k) savings plan with dollar-for-dollar match up to 5% - Tuition Reimbursement - PTO accrual beginning Day 1 Note: Benefits may vary based upon position type and/or level
- EDUCATION - Bachelors or Equivalent Exp
- EXPERIENCE - A minimum of 7 years experience required
Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!