Assistant Director, Medical Management
Oregon, Utah, Idaho or Washington
Provides leadership and oversight for the clinical teams supporting medical management functions such as utilization review and prior authorization. Ensures programs offered are market competitive, compliant with regulatory and accrediting standards, and designed to manage health care costs while achieving quality outcomes. Partners with other clinical and business leaders to establish business objectives, allocate resources and drive results.
General Functions and Outcomes
- Provides leadership in developing, implementing, and communicating short and long-range plans, goals, and objectives for clinical and operations teams. Aligns team goals with the organization's vision and strategy.
- Develops strategies and tactics to effectively manage healthcare costs, improve clinical quality and enhance the member experience for assigned lines of business.
- Collaborates with Medical Directors, Healthcare Informatics, Network Management and other departments as needed to collect, analyze, and report on effectiveness of programs and address quality of care issues. Uses data to guide the development and implementation of health care interventions that improve value to the member.
- Manages the organization by ensuring clear performance expectations along with appropriate skills sets. Fosters an effective work environment and ensures employees receive recognition, feedback and development. Participates in organizational talent management and succession planning.
- Determines appropriate staffing levels and resource needs, creates and manages department and/or project budget, allocates resources, and approves expenditures.
- Oversees the development of effective and efficient clinical policies, procedures and standards. Monitors results and implements process or system changes as needed.
- Ensures clinical programs meet federal and state regulations, accreditation standards, quality metrics, client requirements, and evolving models of care (e.g. accountable care organizations, patient centered homes).
- Makes recommendations as to the use and selection of external vendors. Provides clinical leadership and operational oversight to vendors.
Normally to be proficient in the competencies listed above:
- Demonstrated ability to lead high performing teams, manage managers, and direct vendors.
- Strong communication and facilitation skills with all levels of the organization, including the ability to resolve issues and build consensus among groups of diverse stakeholders.
- General business acumen including understanding of market dynamics, financial/budget management, data analysis and decision making.
- Knowledge of health insurance industry trends and technology.
- Demonstrated ability to create and execute utilization management programs and drive results across internal teams and/or external vendors.
- Extensive knowledge of CMS and state regulatory requirements and demonstrated ability to manage compliant operations. NCQA, URAC and/or HEDIS accreditation experience strongly preferred.
- Ability to decipher and interpret clinical data and deliver presentations to various internal/external audiences related to clinical outcomes.
- Ability to manage production and business metrics including implementing process improvements to drive operational results across the organization.
Assistant Director Medical Management would have a Bachelor's Degree in Nursing, 5 years of progressively responsible clinical care experience, 5 years of management experience, 10 years of experience in health plan case management, utilization management or quality management or equivalent combination of education and experience. Masters preferred.Required Licenses, Certifications, Registration, Etc.
Current unrestricted Registered Nurse (RN) licenseFTEs Supervised
- Work primarily performed in office environment.
- Travel may be required locally or out of state.
- May be required to work outside of normal hours.
Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. We are an equal opportunity employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check is required.
Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We've been here for members for 100 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.
If you're seeking a career that affects change in the health care system, consider joining our team at Cambia Health Solutions. We advocate for transforming the health care system by making health care more affordable and accessible, increasing consumers' engagement in their health care decisions, and offering a diverse range of products and services that promote the health and well-being of our members.
Cambia's portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access and free-standing health and wellness solutions.
This position includes 401(k), healthcare, paid time off, paid holidays, and more. For more information, please visit www.cambiahealth.com/careers/total-rewards
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check are required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com