Provides overall leadership and directs the strategic development of the Resource Stewardship cost management, medical/clinical review, claim coordination and support Regional UM compliance activities. The position has accountabilities and oversight for program scope, resource allocation, budget and staffing requirements. Recruits and retains highly competent individual to implement programs. Determines clinical appropriateness of Hospital Utilization and is involved in any and all programs related to Hospital Services Regionally.
Essential Functions:
Leads through influence and collaboration at all levels of the organization
Provides recommendations into the strategic direction of the department and the Regional Resource Stewardship Program
Identifies opportunities and actively participates and drives process improvements.
Subject Matter Expert in Resource Stewardship activities
Provides direction and oversight of Cost Management Team to ensure clear, accurate, reliable reporting of validated, industry;-standard utilization and cost data
Oversight and responsibility for medical/clinical review /monitoring, cost management/containment, and metric/analytic reporting.
Maintains strong partnerships and key relationships with such areas as, health plan claims, finance, contracting, telephonic medical centers, appeal, primary care , specialty care, and Quality departments to ensure strong collaboration on organization-wide initiatives.
Seeks opportunities to manage/contain costs and enhance resource stewardship functions
Participates in various regional committees as needed to support regional programs and communicate the work of the department
Oversight of Resource Stewardship policies/procedures and templates to assure standardized activities
Supports advancement of organizational improvement initiatives
Provides oversight of external business partners/delegates as appropriate
Responsible for ensuring efficiency, effectiveness and compliance with regulatory standards. Experience in working with regulatory agencies and demonstrated knowledge of compliance requirements and community payer billing/coding and reimbursement guidelines and practices. Responsible for member claims
Qualifications:
Basic Qualifications:
- Minimum of seven years of leadership experience in a clinical and/or healthcare setting.
- Experience in the management and/or oversight of department specific functions driving change and improvement initiatives.
- Solid knowledge of managed care requirements.
- Demonstrated success in the areas of strategic/systems thinking, effective team building, change leadership, and results orientation. -Demonstrated ability to drive focused activities toward a strategic direction as well as develop tactical plans, drive performance and targets.
- Strong logic and analytic skills, excellent verbal and written communication skills, strong facilitation and consulting skills.
- Excellent coaching, mentoring and team development skills.
- Demonstrated skills in emotional intelligence, including areas of intrapersonal and interpersonal awareness, adaptability, and stress management
- Bachelor's degree in business, health care administration or related field.
Preferred Qualifications:
-MBA or Master's of Health Care Administration degree is highly preferred.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.