Dir l/II HCMS
Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.
This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health benefits companies and a Fortune Top 50 Company.
Responsible for the development, implementation, and oversight of integrated Medical Management of more than one member population type with varying degrees of medical complexity. Oversees case and utilization management execution/decision making for managed member populations. Is accountable to plan executive or executive team member dependent on plan size/complexity and is involved in the development of the strategic vision, goals, and objectives for medical management. Serves as liaison to state regulatory agencies. Primary duties may include, but are not limited to:
- Directs and provides leadership for designing, developing, and implementing integrated medical management program to meet the demographic and epidemiological needs of the populations serviced.
- Partners with other health plan/corporate leaders to develop and deliver innovative care management services, root cause analyses and solutions to achieve quality outcomes.
- Directs Healthcare Management Program including disease management,behavioral health case management, and utilization management.
- Partners with Provider Relations, Quality Management, Health Promotions, and Community Relations to develop and implement effective provider communications, quality assurance, and member outreach programs.
- Provides expert consultation to local plan staff on benefits interpretation and utilization and quality management matters.
- Ensures support for compliance with National Committee for Quality Assurance (NCQA) and assures compliance with state/and or federal program requirements.
- Hires, trains, coaches, counsels, and evaluates performance of direct reports.
- Requires a BA/BS in a health care field; 10 years of clinical work experience, including prior management experience; or any combination of education and experience, which would provide an equivalent background.
- Previous experience with NCQA accreditation and HEDIS reporting required. RN, LCSW, or LPC strongly preferred.
- Masters in a health care field or MBA with Health Care concentration preferred.