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Job SummaryThis position is responsible for leading and managing the development, implementation, strategic day-to-day administration of managed care operations across clinical functions (utilization management, case management and disease management). 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 HCSC's 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 HCSC's clinical operations customer service is compliant with internal and external requirements.**This is a Flex position (in the office 3 days a week)****Position can be located in Albuquerque, NM or Richardson, IL or Tulsa, OK**JOB REQUIREMENTS:- Required Licensed Registered Nurse (RN) with 2 years of experience in a clinical/surgical setting in the state of operations.
- 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.
- 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
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HCSC Employment Statement:HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.