AVP - Medicaid Healthcare Management

BlueCross BlueShield of South Carolina•Columbia, SC

2d•Hybrid

About The Position

The AVP, Medicaid Healthcare Management provides leadership, direction, and oversight (clinical operations) in the establishment of strategic direction for physical and behavioral health Utilization Management (prior authorization, inpatient review), Case Management, and Population Health. In this role, you will collaborate with internal and external partners in the development of various programs and strategies in support of current and emerging Medicaid business needs. The strategic leader that we seek will have a passion for working with Medicaid populations, as well as exceptional team building and team development skills.

Requirements

Master’s Degree or equivalent combination of education and work experience.
10+ years of managed care experience with at least 5 years in direct Medicaid Managed Care.
Experience working within applicable state, federal and third-party regulations.
Experience meeting Quality Accreditation Standards (NCQA/HEDIS/STARS).
Working knowledge of word processing software.
Knowledge of quality improvement processes and demonstrated ability with these activities.
Knowledge of contract language and application.
Ability to work independently, prioritize effectively, and make sound decisions.
Good judgment skills.
Demonstrated customer service, organizational, and presentation skills.
Demonstrated proficiency in spelling, punctuation, and grammar skills.
Demonstrated oral and written communication skills.
Ability to persuade, negotiate, or influence others.
Analytical or critical thinking skills.
Ability to handle confidential or sensitive information with discretion.
Active, unrestrictive SC Registered Nursing (RN) license, Advanced Practice Registered Nursing (APRN) license or Physician Assistant (PA) license in good standing.
Microsoft Office 365

Nice To Haves

Master’s Degree in Business or Healthcare management (i.e. MBA, MHA, MHP).
Strong Medicaid knowledge and experience.
Working knowledge of spreadsheet, database software.
Thorough knowledge/understanding of claims/coding analysis, requirements, and processes.
Utilization Management Certification (CPHM), Certified Professional in Health Care Quality (CPHQ) or other healthcare or management certifications.
Ability to develop and maintain positive relationships with peers, enterprise, customers, and partners.
Demonstrated ability to drive continuous improvement and cost reduction.
Ability to effectively collaborate with cross-functional teams.
Executive level presentation skills.
Experience working with the SC Department of Health and Human Services.
Strong team building and team development skills.

Responsibilities

Provides strategic direction and operations oversight of Medicaid physical and behavioral health medical management programs including Utilization Management, Case Management, Population Health, and Complex Case Management.
Achieves a positive return on investment for each program.
Completes annual strategic and operational plans, budgets, etc.
Implements and maintains monthly, quarterly, and annual performance monitoring to ensure compliance to contract, State, and Federal requirements/regulations
Provides strategic direction and operations oversight to cutting edge programs and strategies for Medicaid Medical Management.
Provides direction, oversight, and management of any analytical projects and product/service development in support of Medical Management programs.
Establishes, guides, and analyzes effective operations against benchmarks that are developed as measures of success.
Analyzes performance trends and develops new or modified work processes, decision support systems, reporting and benchmarks to improve overall operations quality, timeliness, member satisfaction, and financial outcomes.
Mentors, guides and develops skills of management team members in a consistent and effective manner.
Establish and maintain staff productivity standards to ensure compliance with contractual, accreditation and regulatory requirements.
Evaluates the clinical and economic impact of program and ensures all operations meet the program’s overall objectives and requirements.