• Health Services Director

    Req No.
    2018-3192
    Company
    Sendero Health Plans
    Job Locations
    US-TX-Austin | US-TX-Austin
    Category
    Management
    Type
    Regular Full-Time
  • Overview

    This position is responsible for managing the activities of the Health Services department.  Key responsibilities include managing quality improvement, utilization management, behavioral health management, pharmacy and the Whole Person Health Support program (case management and disease management programs).  This position works with a wide range of internal and external people including providers and internal staff.

    Responsibilities

    • Develops, implements, and manages the programs within the Health Services department which include quality improvement, utilization management, behavioral health, pharmacy and the Whole Person Health Support program.
    • Provides leadership in the evaluation of the program’s effectiveness in improving the care and services to members including special needs members; addressing under and overutilization of services; ensuring that members receive the benefits that are medically necessity and appropriate, and providing supporting to members in the management and self management of selected health care conditions and/or selected episodes of care.
    • Manages the resolution of pharmacy appeals.
    • Ensures timely and appropriate actions are taken when quality of care issues have been validated.
    • Collaborates with the VP Operations in conducting clinical oversight of the PBM and credentialing delegates.
    • Manages the operational and fiscal activities of the department including; staffing levels, budgets, financial goals and operating goals, plans and develops systems procedures to improve quality and efficiency of operations and meet productivity and quality goals.
    • Hires and supervises staff in accordance with personal policies and procedures including; orientation and training, career development, employee goals, performance reviews, coaching, counseling and staff disciplines including termination, if needed.
    • Coordinates and participates in the Quality Improvement Committee, Provider Advisory Subcommittee and the Service Advisory Subcommittee.
    • Ensures compliance with all applicable state and federal regulatory requirements.
    • Performs other duties as required.

    Qualifications

    • Demonstrated leadership and management skills.
    • Comprehensive knowledge and understanding of medical management components including quality improvement, utilization management, disease management, behavioral health management, pharmacy management and case management.
    • Ability to negotiate complex and sensitive clinical issues while retaining strong working relationships with providers and members.
    • Ability to interpret claims and clinical data, develop corrective action programs and implement effectively.
    • Basic understanding of other managed care functions including network management, customer service and claims.
    • Strong problem solving skills with effective follow through.
    • Strong listening, verbal, presentation and written communication skills.
    • Excellent interpersonal skills with ability to interface effectively internally and externally with a wide range of people including physicians, regulators and health plan other staff.
    • Basic understanding of NCQA accreditation standards.
    • Basic understanding of Texas regulatory requirements for CHIP and Medicaid is desirable.
    • Graduate from an accredited School of Nursing or related clinical field.
    • Master’s degree preferred.
    • Five years experience in the following areas utilization management, disease and/or case management
    • A working knowledge of quality improvement
    • A minimum of two years in a supervisory capacity in the health service field

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