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This job was posted by https://idahoworks.gov : For more information, please see: https://idahoworks.gov/jobs/2307393 Blue Cross of Idaho (BCI) is uniquely positioned as a well-capitalized, leading healthcare payer in its market, serving hundreds of thousands of Idahoans and partnering with premier employers across the state. The Vice President (VP) of Medical Management is responsible for providing leadership and direction for all areas of medical management to include care management, quality management, utilization management, and mental health for all lines of business. This role works closely with various segments of the company to ensure delivery of affordable, accessible healthcare benefits to members. The VP, Medical Management is responsible to implement processes that reduce healthcare delivery costs and improve productivity, effectiveness, and efficiency of medical management operations.

This position is reports to the Chief Medical Officer and is located at the corporate headquarters in Meridian, Idaho. #LI-Onsite

To be considered for this role, you have:

Required Experience:

• Minimum of ten years health plan managed care (either with a medical group or health plan) utilization management, health care quality improvement (such as NCQA, CMS), and in the development and implementation of clinical practice guidelines and policy at a senior level

Required Education:

• Bachelor\'s Degree or equivalent work experience (Two years\' relevant experience is equivalent to one-year college)

We\'d also love it if you had:

• Previous or current unrestricted license in a clinical designation of RN or higher
• Master of Business Administration (MBA) or equivalent subject area

Key responsibilities of the role:

• Design business plans and technology solutions to implement the clinical strategy.
• Improve department efficiency through effective use of information system tools and processes to reduce healthcare cost, increase quality, and reduce administrative expense.
• Develop, implement, and distribute regular performance and productivity reports.
• Provide direction, support, and medical expertise in matters of case and disease management/population health, underwriting, and review of health statement applications, claims and inquiries that require medical review.
• Partner with Healthcare Economics, Account Management, and Sales to deliver innovative and efficient approaches to classic utilization management, case management, and disease management processes.
• Ensure ongoing programmatic excellence, thorough program evaluation, and consistent quality of administration, communications, and systems.
• Collaborate with go-to-market leaders in deepening and refining all aspects of member touchpoints.
• Support the Sales/Marketing division in communicating to prospective clients the role that Healthcare Operations plays in the control of healthcare costs.
• Develop presentations on effectiveness of Medical Management programs for BCI Board of Directors.
• Responsible for scope and performance of Quality Management activities approved by the governing board and as required to meet private, federal, or state accreditation.
• Participate with Provider Network Management to facilitate contract negotiations with physicians and hospitals.
• Collaborate with Provider Network Management to implement reimbursement strategies, including but not limited to, quality incentives and pay for performance.
• Assist in and/or establish department objectives that support organizational goals and produce regular status reports.
• Assist in and/or prepare an annual operating budget that reflects the forecasted needs of the department and control expenditures to assure adherence to approved budgets.
• Ensure effective workflows, improve system efficiencies, monitor quality performance measures and confirm appropriate completion of work assignments. Lead change as appropriate.
• Participate in training, coaching and motivation of employees including career path development. Assess individual employee performance and conduct timely performance appraisals.
• Promote teamwork, discussion, and cooperation among staff and other departments. Ensure timely communication and sharing of information with team members.
• Initiate personnel actions such as hiring, disciplinary, termination and/or salary recommendations. Work with staff to resolve work-related issues and concerns. Promote a respectful and diverse workplace.
• Develop and maintain departmental policies and procedures.
• Perform other duties as requested

To be successful in this position, you have the following:

Knowledge of:

Case/Disease/Utilization Management productivity measurements, inter-rater reliability metrics, and interdisciplinary team dynamics

Demonstrated knowledge of healthcare and business processes related to delivery systems

Healthcare