HCMS Director

Elevance Health•Brainerd, MN

3d•Hybrid

About The Position

HCMS Director Location: Washington, DC. This role requires associates to be in-office 4 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of remote work, promoting a dynamic and adaptable workplace. Alternate locations may be considered. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The HCMS Director will be responsible for managing the utilization or care management process for one or more member product populations of Physical Health and/or Behavioral Health of varying medical complexity ensuring the delivery of essential services that address the total healthcare needs of members. How you will make an impact: Implements and manages health care management, utilization, cost, and quality objectives. Ensures program compliance and identifies opportunities to improve the customer service and quality outcomes. Oversees the development and execution of medical and case management policies, procedures, and guidelines; assists in developing clinical management guidelines. Ensures medical management activities are contracted, reviewed and reported. Supports quality initiatives and activities including clinical indicators reporting, focus studies, and HEDIS reporting. Serves as liaison to state regulatory agencies. Drives direction of the plan related to cost of care and other plan directives. Ensures program compliance and identifies opportunities to improve the consumer experience and quality outcomes.

Requirements

Requires a BA/BS degree in a health care field and a minimum of 8 years clinical experience including prior management experience; or any combination of education and experience which would provide an equivalent background.

Nice To Haves

RN, LCSW, or LPC preferred.
National Committee for Quality Assurance (NCQA) accreditation and HEDIS reporting experience preferred.
MS/MA degree in a health care field or MBA with Health Care concentration preferred.
Certified Case Manager preferred.

Responsibilities

Implements and manages health care management, utilization, cost, and quality objectives.
Ensures program compliance and identifies opportunities to improve the customer service and quality outcomes.
Oversees the development and execution of medical and case management policies, procedures, and guidelines; assists in developing clinical management guidelines.
Ensures medical management activities are contracted, reviewed and reported.
Supports quality initiatives and activities including clinical indicators reporting, focus studies, and HEDIS reporting.
Serves as liaison to state regulatory agencies.
Drives direction of the plan related to cost of care and other plan directives.
Ensures program compliance and identifies opportunities to improve the consumer experience and quality outcomes.