Location: This position is full-time (40-hours/week) Monday-Friday HYBRID at our 4101 Percival Road, Columbia, SC location. You will be required to work 2 days in-office.
Sponsorship: This position is not eligible for sponsorship now or in the future.
What You’ll Do:
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..
To Qualify for This Position, You'll Need the Following:
Required Education: Master’s Degree or equivalent combination of education and work experience.
Required 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).
Required Skills and Abilities:
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.
Required License and Certificates: Active, unrestrictive SC Registered Nursing (RN) license, Advanced Practice Registered Nursing (APRN) license or Physician Assistant (PA) license in good standing.
Software and Tools: Microsoft Office 365
Work Environment: Typical office environment. Must reside in South Carolina.
We Prefer That You Have The Following:
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.
Our Comprehensive Benefits Package Includes The Following:
We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.
Subsidized health plans, dental and vision coverage
401k retirement savings plan with company match
Life Insurance
Paid Time Off (PTO)
On-site cafeterias and fitness centers in major locations
Education Assistance
Service Recognition
National discounts to movies, theaters, zoos, theme parks and more
What We Can Do for You:
We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.
What To Expect Next:
After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.
Management will be conducting interviews with those candidates who are the most qualified, with prioritization given to those candidates who demonstrate the required qualifications.
Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.
If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
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