JOB SUMMARY: Responsible for management and implementation of all operational and functional support for the Health Plans Health Services Division (HSD). Directs and coordinates all operations to ensure complete compliance with policies/procedures, accreditation and regulatory standards. Coordinates and implements IS programs/management for support of HSD Programs.
WHAT IS EXPECTED (Essential Functions):
Coordinates and directs SWHP health services: Responsible for the management and oversight of the HSD functions. These functions include performance of prospective, concurrent and retrospective utilization review, as well as appeals and grievances. The Director works closely with staff from Intake Support, Utilization Management, Case Management, Claims Nurse Review Operations, Appeals and Grievance, and Monitoring and Training units on these review activities. He/she is responsible for the monitoring and oversight of the activities performed within the HSD and the delivery and review of defined metrics to validate business unit/program effectiveness and ensure appropriate resources are assigned to meet needs. Reporting directly to the VP, Health Management on program delivery and aids leadership in formulating innovations to support at-risk strategies, strategic planning, and operational improvement processes with an emphasis on improved healthcare cost and quality. The director works collaboratively with Health Care Services and other appropriate SWHP departments across product lines to identify and address opportunities to improve service, reduce administrative cost and support department and organizational business goals. Manages vendors delegated to perform specific HSD operations. He/She is also accountable for direct supervision, evaluation, management and ongoing development of reporting staff.
Designs and builds a dashboard and Key Performance Indicators which will provide for accurate assessment of Utilization and case management performance including key performance measures which assess the effectiveness of communication, the effectiveness (access, timeliness, efficiency, quality) of care transition to other levels of care, general cost, and utilization trending. He/she is charged with ensuring compliance with requirements for all regulatory and accreditation authorities related to the work and is responsible for ensuring the HSD departmental processes are applied and followed by his/her direct reports.
Develops, implements and/or updates HSD program policies and procedures, operational guidelines and process workflows: Assures that policies and procedures, operational guidelines and process workflows are current and meet regulatory and accreditation standards. Directs communication plan and/or training oversight for staff, including easy access for reference (online preferred).Offers input and assists with development of education and training programs. Maintains accurate and timely reporting of HSD Program activities. Assists in the development of management reporting and coordinates with HSD Managers/Supervisors in development of and understanding of management reporting to effectively manage the delivery of services.
Provides required reports and special projects related to RFPs, TPA reporting, etc. as requested and on time.
Assists in the development and implementation of appropriate hsd systems for coordinaton of work within the plan and with other plan programs: Provides input and direction to Information Technology (IT) at Plan level and system level (as needed) on required HSD system issues and enhancements or replacements. Coordinates data field population requirements with internal and external system reporting requirements to ensure continuity of care documentation for Plan Members in SWHP HSD system.
Responsible for all system coordination and implementation processes for SWHP HSD. Supports CMS reporting requirements, data validation audits, NCQA accreditation preparation and other reviews ensuring all compliance with statutory, regulatory and accreditation requirements and timeliness. Responsible for quality of service rendered from SWHP HSD: Provides strong leadership role model for supervisors and staff, including offering coaching and mentoring where needed. Maintain and improve engagement and commitment to work within all levels of HSD staff/management and participating in team meetings. Monitors and reports any health service issues or concerns to HSD leadership (VP/CMO) and works collaboratively with those identified to assure quality service delivery that meets internal and external customer expectations. Works, communicates and collaborates in a courteous and professional manner with staff, members, practitioners, and employers while serving as a member advocate and liaison for quality of services and cost outcomes for the Plan.
Performs other position appropriate duties as required in a competent, professional and courteous manner.
KNOWLEDGE, SKILLS, and ABILITIES:
Knowledge and experience in managed health care operations. Ability to work self-directed required. Strong results orientation - drives to meet business goals. Ability to handle multiple demands--must be able to effectively balance multiple priorities. Good operational and project management skills. Ability to deliver excellence under a tight time frame.
Excellent communication skills both written and verbal. Ability to oversee assessment, development and implementation of initiatives and monitor implementation and modify accordingly. Proficiency with MS Office, Word, Excel, & Access. 1+ year of Management experience
Bachelors degree Required or equivalent combination of education and experience
Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!