Cost Containment and MLR Optimization Program Lead

BlueCross BlueShield of South Carolina•W@H South Carolina, SC

4d•Remote

About The Position

We are currently hiring for a Cost Containment and MLR Optimization Program Lead to join BlueCross BlueShield of South Carolina. In this role as a Cost Containment and MLR Optimization Program Lead, you will be responsible for the development and management of various health management programs to include Case Management, Disease Management, Utilization Management, Behavioral Health, and Healthcare Development, you will assess impact of programs which may include: performs cost-benefit/feasibility analyses, performs market research assessing corporate competitiveness, and provide strategic direction for reporting, including design, analysis, and validation of outcomes and ROI. Develops, implements, evaluates, and maintains health management programs. Positions BCBSSC to compete effectively with other companies. Achieves positive return on investment through oversight of new product/technology development and promotion of service enhancement strategies to increase customer retention. Develops and conducts health management presentations to management, internal and external customers that are informative and customized to meet health plan and customer needs. Establishes reporting mechanism that details clinical outcomes, utilization statistics and ROI. Develops and maintains specific reporting to include tracking of efficacy, clinical/financial outcomes, research analysis, and the accuracy/timeliness of data collection. Provides leadership and direction to staff through employee development, management training, and budget oversight. Develops, implements, complies with and promotes staff adherence to corporate and department policies, procedures, and performance and communication standards. Complies with and monitors adherence to URAC case management standards, SC Department of Insurance regulations, SC Nurse Practice Act, all applicable state and federal laws and standards of national accreditation agencies, as management deems necessary.

Requirements

Bachelors in a job-related field.
Graduate of Accredited School of Nursing. (Equivalency not applicable for the Celerian Group. Bachelor's degree required.)
5 years’ clinical or experience developing, implementing and evaluating population health programs with two of the five years in a supervisory role or equivalent military experience in grade E4 or above.
Ability to understand and communicate healthcare policy.
Working knowledge of word processing, spreadsheet, and presentation software.
Ability to work independently, prioritize effectively, and make sound decisions.
Demonstrated customer service, organizational, research, and presentation skills.
Demonstrated verbal and written communication skills.
Analytical, critical thinking, and math skills necessary to collect, analyze, and report data.
Highly developed knowledge of planning, programming, and budgeting activities.
Ability to persuade, negotiate, or influence others.
Ability to handle confidential or sensitive information with discretion.
Ability to direct, motivate, and assess performance of others.
Microsoft Office.
If RN, active, unrestricted RN licensure from United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR if Social Worker or Counselor, active unrestricted licensure as Social Worker or Counselor from the United States and in the state of hire (for Div. 75 only).

Nice To Haves

Prior knowledge/experience with Medicare Advantage.
Must be proficient in software systems including SAS, Tableau, and Microsoft Excel.
Must have excellent communication skills as the candidate will be working directly with vendors and internal teams.
Must have a high degree of technical and analytical skills.
Must have keen attention to detail and exceptional time management skills

Responsibilities

Develops, implements, evaluates, and maintains health management programs.
Positions BCBSSC to compete effectively with other companies.
Achieves positive return on investment through oversight of new product/technology development and promotion of service enhancement strategies to increase customer retention.
Develops and conducts health management presentations to management, internal and external customers that are informative and customized to meet health plan and customer needs.
Establishes reporting mechanism that details clinical outcomes, utilization statistics and ROI.
Develops and maintains specific reporting to include tracking of efficacy, clinical/financial outcomes, research analysis, and the accuracy/timeliness of data collection.
Provides leadership and direction to staff through employee development, management training, and budget oversight.
Develops, implements, complies with and promotes staff adherence to corporate and department policies, procedures, and performance and communication standards.
Complies with and monitors adherence to URAC case management standards, SC Department of Insurance regulations, SC Nurse Practice Act, all applicable state and federal laws and standards of national accreditation agencies, as management deems necessary.