Director, Government Programs Clinical Operations

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development.

Job Summary This position is responsible for directing change in processes and the integration of projects for Government Programs Clinical Operations to include Medicare Advantage, Dual Eligibles, and Medicaid products across Medical Management organizations; optimizing the clinical review process across Operations, Marketing/Sales and Medical departments; ensuring Plan maintains compliance with accreditation standards and government regulations; directing and developing cost of care initiatives and clinical management tools ensuring that quality, expense and performance drivers are operational;

overseeing triage and reporting of high dollar claims; directing quality analysis, performance analysis, and customer service standards and metrics of Medical Management teams; and overseeing performance guarantees and implementing performance improvement plans to address variances. Direct change in processes and integration of projects for Government Programs Clinical Operations products in medical management organizations across the enterprise. Execute on implementation and completion of projects to address strategies for Government Programs Clinical Operations products and services.

Accountable for optimizing the clinical review process across various departments including Operation, Marketing/Sales and Medical. Ensure Plan maintains compliance with accreditation standards and government regulations. Direct and develop cost of care initiatives and clinical management tools ensuring that quality, expense and performance drives are operational. Oversee triage and reporting of high dollar claims. Direct quality analysis, performance analysis and customer service standards and metrics for Government Programs Clinical Operations medical management teams.

Oversee performance guarantees and implementing performance improvement plans to address variances. Manage staff and the meeting/exceeding goals, address changes to ensure goals are met, includes but not limited to goal setting, performance management, pay administration, diversity, change management, professional development and talent management. Maintain knowledge of Government Programs and Marketplace and change in products, services, processes and regulations. Maintain clinical licensure.

Communicate and interact effectively and professionally with co-workers, management, customers, etc. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies. Maintain complete confidentiality of company business. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

• Direct change in processes and integration of projects for Government Programs Clinical Operations products in medical management organizations across the enterprise.
• Execute on implementation and completion of projects to address strategies for Government Programs Clinical Operations products and services.
• Accountable for optimizing the clinical review process across various departments including Operation, Marketing/Sales and Medical.
• Ensure Plan maintains compliance with accreditation standards and government regulations.
• Direct and develop cost of care initiatives and clinical management tools ensuring that quality, expense and performance drives are operational.
• Oversee…