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Director - HP Medical Management Administrator Banner Health Job at ASHHRA

Mesa, Arizona, Primary City/State: Mesa, Arizona Department Name: HP Statewide Plan Admin Work Shift: Day Job Category: General Operations Help lead health care into the future. As one of the largest nonprofit health systems in the country, Banner Health has both the stability that comes with success and the values you can be proud to represent. If you e looking to leverage your abilities - you belong at Banner Health. The Director - HP Medical Management Administrator will report directly COO of Banner University Health Plans and will be position responsible for management requirements under AHCCCS policies, State regulations, rules, and Contract. This position will work closely with the Clinical Leadership teams for Banner University Health Plans and other department with in Banner Insurance Division as the clinical resources to meet the evolving regulatory requirements of the ACC, ALTCS, DSNP programs as well as support other new business expansion opportunities. A strong clinical foundation as an RN in medical management plan, model of care, and other regulator clinical requirements will be a strong asset in this role. The Director - HP Medical Management Administrator can sit in either Mesa or Tucson Arizona. Your pay and benefits are important components of your journey at Banner Health. This opportunity is also eligible for our Management Incentive Program, as part of your Total Rewards package. Banner Health offers a variety of benefits to help you and your family. We provide health and financial security options so you can focus on being the best at what you do and enjoying your life. Banner University Health Plans (BUHP) manage a variety of health plans. Our mission is to advance health and wellness through education, research and patient care. About Banner Health Banner Health is one of the largest, nonprofit health care systems in the country and the leading nonprofit provider of hospital services in all the communities we serve. Throughout our network of hospitals, primary care health centers, research centers, labs, physician practices and more, our skilled and compassionate professionals use the latest technology to make health care easier, so life can be better. The many locations, career opportunities, and benefits offered at Banner Health help to make the Banner Journey unique and fulfilling for every employee. POSITION SUMMARY The primary purpose of this position is to manage the utilization management and case management clinical programs and operations for the Health Plans. Medical Management ensures members access to and satisfaction with quality health care, as well as appropriate utilization of health care services. As a key leadership role, this position will work collaboratively with all members of the leadership team to provide cross organizational leadership. This position performs all related duties in a manner that is consistent with and in support of the organizations mission, vision, values and goals. CORE FUNCTIONS 1. Responsible for the leadership of Medical Management, which includes Utilization Management departments within the Health Services division as well as Case Management as it relates to the Plans Medicaid (AHCCCS) and Healthcare Group of Arizona (HCGA) populations. 2. Responsible for the leadership of Case Management, which includes the Case and Disease Management, Maternal-Child Health, and Behavioral Health departments in the Health Services division in conjunction with the Director of Care Management of Medicare. The position will focus on ensuring appropriate utilization and case management, which focuses on helping members to obtain the right care in the right place at the right time to achieve better overall health status. It is the evaluation of the appropriateness, medical need and efficiency of health care services, procedures and facilities. The evaluation is according to established criteria and guidelines, and under the provisions of an applicable health benefits plan. It includes proactive procedures and processes, such as pre-certification, concurrent planning and reviews, peer reviews, discharge planning, and clinical case appeals. 3. The position will be responsible for ensuring cross collaborative integration with other key Medical Management functions, such as care management, condition management, behavioral health, maternal-child health, quality management, pharmacy, as well as non-clinical collaboration with Health Plan operational departments. As a member of the senior leadership team, the Director of Medical Management provides strategy and direction of Medical Management operations, assuring efficient and effective operations, ultimately impacting positive financial and clinical outcomes. This position will be a member of the Directors, Operations and other key leadership teams within the organization to ensure consistent leadership, collaboration and communication across the organization. 4. Collaborates with the Director of Quality and Performance Improvement in designing, implementing, and measuring the efficacy of interventions that were implemented to as a result of data analysis or recommendations from quality investigations. Oversees the submission of required data internally and externally, such as to AHCCCS. Assures data meet requirements of AHCCCS and HCGA. Protects the financial interests of the organization and clinical interests of members through continuous review, oversight and management of all aspects of the Medical Management areas within the organization, which includes utilization, and case management activities, inclusive of services affecting AHCCCS and HCGA members. Monitors and assesses the effectiveness of both CM and UM interventions, using metrics/reports to inform decisions and improve interventions. Works with the Medical Director, in the development and ongoing improvement for Utilization and Case Management programs for managed care patients and providers. Seeks to continually improve member satisfaction and health outcomes. 5. Oversees the Medical Management Systems Department that retrospectively clinically reviews claims submissions, coordinates data reporting to Medical Management areas, provides training as needed regarding information systems, and coordinates inter rater reliability testing for all Medical Management staff. 6. Develops effective, well-defined and supported UM processes and functions for Medicaid and HCGA and any other populations served, and manages them collaboratively across the organization. Develops effective, well defined and supported CM processes and functions for Medicaid and Healthcare Group and works collaboratively with the Director of Care Management to support her/his management of dual eligible and Special Needs Population members. Develops and implements business requirements for UM and CM, leveraging technology areas used to support UM and CM delivery, for both internal and on-site delivery. Provides oversight to maintaining appropriate UM and CM staffing levels are maintained and providing training for new and existing staff in a consistent format to ensure the integrity of the UM and CM Programs. Supports staff satisfaction and retention through education, training, recognition, leadership, and provision of resources required to do each job effectively. 7. Provides ongoing education for staff regarding utilization management theory and processes, the requirements of AHCCCS/HCGA , and organizational policy. Develops inter- and intra-departmental systems and monitors utilization processes to comply with all aspects of contracts with regulatory and non-regulatory agencies regulations to ensure continued viability of all Health Plan products. Develops policies and procedures and assures such policies are consistent with the requirements of AHCCCS and HCGA as well as other selected regulatory agencies, and applicable contracts. Assures compliance with state and federal regulation. 8. Acts as the clinical liaison with State HCGA and AHCCCS for the UAHN Utilization Management and Case Management programs. Provides vision and clinical operations leadership to UM staff in the delivery of UM programs. Provides vision and clinical operations leadership to CM staff in the delivery of CM programs. Supervises and manages the utilization and case management functions to include referral processing, concurrent hospital review, discharge planning, medical claims review, denials, admissions, case management and transitions. Operates with high integrity and principles. Creates a positive environment where staff are motivated to do their best work. Demonstrates high respect for others in all interactions and drives expectations for respect for the team. 9. This position has facility/entity-wide responsibility for medical management services. Internal customers include organizational leaders of the Health Plan, Case Management, Behavioral Health and other Medical Management functions. External customers: Patients and families regarding patient care issues; physicians regarding patient care and program development; agency vendors and contracted services; staff from other health care agencies/providers and community/professional organizations for the purpose of exchanging patient and program information and insurance payers; state, federal and community agencies regarding compliance with laws and regulations. Must have knowledge of the requirements of national/state accrediting agencies, such as NCQA, HEDIS, Medicare (CMS) and Medicaid (AHCCCS). MINIMUM QUALIFICATIONS Bachelors degree in Nursing is required. Requires a current licensure as a Registered Nurse in the State of Arizona. Requires five to seven years of director level experience in health care management, and prior experience in progressively responsible roles in health care management, including utilization management is required. Experience in a case, utilization, or quality management leadership role is preferred. Experience with development and implementation of benchmarks, metrics, and measurements. Must have knowledge of quality improvement processes. Must have knowledge of the requirements of national/state accrediting agencies, such as NCQA, HEDIS, Medicare (CMS) and Medicaid (AHCCCS). Must be able to demonstrate successful experience and program development/improvement in medical management programs, including concurrent review and case management. Excellent communication skills are required, as are analytical, problem solving and computer skills and the ability to create, manipulate and manage databases. Must possess the ability to prepare and deliver presentations that summarize, analyze, and interpret data and make recommendations for courses of action for program and operational changes. Must possess the ability to lead, work collaboratively with, and implement plans with multi-disciplinary teams. Must possess the ability to establish strong working relationships and work collaboratively with key internal and external stakeholders, including staff, peers, medical directors, providers, AHCCCS and other health system leaders. PREFERRED QUALIFICATIONS Masters degree in Business, Healthcare, or a related field is preferred. Additional related education and/or experience preferred. DATE APPROVED 06/07/2015
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ID: 32051664 - Save Job
Category: Jobs : Education Jobs
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The American Society for Health Care Human Resources Administration (ASHHRA) is the nation’s only membership organization dedicated to meeting the needs of human resources professionals in health care.


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