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Executive Director, Government Programs Clinical Operations (TX MEDICAID)

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Health Care Service Corporation

15d ago

  • Job
    Full-time
  • Healthcare
  • Richardson

AI generated summary

  • You need a clinical license, 3 years in clinical settings, 10 years management, 15 years in health insurance, project management experience, and knowledge of Medicaid/Medicare processes.
  • You will oversee health care management programs, set performance targets, ensure regulatory compliance, represent the company, manage medical care operations, and supervise director-level staff.

Requirements

  • Clinical license (RN, LCPC, LMSW, LISW) currently licensed with 3 years experience in a clinical setting.
  • 10 year management experience.
  • 15 years health insurance experience in Utilization Management, Case Management or Quality Management.
  • Knowledge of traditional Medicare, or Dual Eligible, or Medicaid claims payments rules and their impact on care management processes. Experience developing business requirements and reporting.
  • Project management experience in the planning, implementation, and review of medical processes.
  • Knowledge of accreditation standards (ie; NCQA or URAC).
  • Experience in the creation, development and implementation of process improvement and instilling that focus in a team.
  • Experience developing high-level strategies; strategic thinker and implementer.
  • Knowledge of managed care principles and delivery systems.
  • Knowledge or experience with quality improvement.
  • Knowledge of healthcare/insurance industry, trends, regulations and future market needs.
  • Knowledge of managed care service delivery processes, workflow, systems, reporting needs, training and quality.
  • Collaborative leadership and teambuilding skills including influencing, leading and directing individuals in multiple functional areas.
  • Analytical skills.
  • Verbal and written communication skills including interpersonal skills and skills to develop and facilitate presentations to management and executives.
  • PC skills and experience to include Excel, PowerPoint, and Access.
  • Ability and willingness to travel, including overnight stays.
  • PREFERRED JOB REQUIREMENTS:
  • Advanced degree in business, public health, administration or other business field.
  • Certification in Case Management, Health Care Administration or Project Management.
  • Clinical leadership and management experience focused in serving the elderly, chronically ill, disabled, low income or frail population.
  • Medicare Advantage or Dual Eligible or Medicaid experience.

Responsibilities

  • - Directing the execution and delivery of specific health care management programs
  • - Establishing value improvement goals, objectives, metrics, and other key performance targets for government programs clinical operations
  • - Ensuring compliance with all applicable certification and accreditation entities as well as government regulators
  • - 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
  • - Overseeing director level personnel and other upper management in the operations of the government programs clinical operations

FAQs

What qualifications are required for this position?

A clinical license (RN, LCPC, LMSW, LISW) with a minimum of 3 years of experience in a clinical setting, along with 10 years of management experience and 15 years of health insurance experience in areas such as Utilization Management, Case Management, or Quality Management are required.

Is previous experience with Medicaid or Medicare necessary?

Yes, knowledge of traditional Medicare, Dual Eligible, or Medicaid claims payment rules and their impact on care management processes is essential for this role.

What level of management experience is preferred for this role?

The role requires 10 years of management experience, specifically focused on health insurance operations.

Are there specific accreditation standards I should be familiar with?

Knowledge of accreditation standards such as NCQA or URAC is important for this position.

What skills are essential for collaboration and leadership in this role?

Collaborative leadership and team-building skills, including the ability to influence, lead, and direct individuals across multiple functional areas, are essential.

Is travel required for this position?

Yes, the position requires the ability and willingness to travel, including overnight stays.

Are there preferred qualifications or certifications for this role?

Yes, an advanced degree in business, public health, administration or a related field, along with certifications in Case Management, Health Care Administration, or Project Management, are preferred.

What is the work environment like at HCSC?

HCSC is committed to providing an inclusive workplace where unique differences are welcomed, respected, and valued, promoting a diverse work environment.

Will the position involve overseeing other staff?

Yes, the role includes overseeing director-level personnel and other upper management in the operations of government programs clinical operations.

Is there any specific technology or software expertise required for this position?

Proficiency in PC skills, including Excel, PowerPoint, and Access, is required for this role.

Health Care Service Corporation

Empowering Whole Person Health With Compassion and Innovation

Science & Healthcare
Industry
10,001+
Employees

Mission & Purpose

Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), is an Independent Licensee of the Blue Cross and Blue Shield Association. We are the largest customer-owned health insurer in the United States, serving more than 18.6 million members through our Plans in Illinois, Montana, New Mexico, Oklahoma, and Texas. For nearly a century, we have enabled and coordinated the access to quality care for millions of members. Our experience and industry knowledge establishes a solid foundation for our future—driving innovations that further expand access, improve health outcomes, and reduce costs. Embedded within the fabric of how we operate is a deep sense of caring and commitment that informs how we serve our members, engage in local communities, and deliver positive change to the health care industry. As health care needs evolve, we leverage our portfolio of companies to deliver differentiated value to all industry stakeholders so that, together, we make more possible.