Director, Plan Performance – Georgia

  • Full Time
  • Atlanta, GA
  • Applications have closed

CareSource

Description

Role and Responsibility:
Provide oversight, creation and management of all market provider incentive plans
Manage the provider incentive plans to comply with state and federal contractual requirements
Manage the state managed care incentive program to maximize health plan reimbursement
Develop, disseminate and drive the education of providers on opportunities to maximize their reimbursement
Develop criteria for prior authorizations, benefit limits, etc. to meet state requirements and manage PMPM cost for select services
Takes information from finance as needed to target select expenses with high degree of impact on MCR initiatives.
Interacts with providers as needed to provide education based on managed care industry standards.
Provides support to health partners in training and managing providers relative to provider performance. .
Partner with market and enterprise leaders on the development of overall health strategy and business objectives in order to ensure business success in multiple lines of business
Responsible to execute on market strategy and drive market performance; align and integrate operations, systems, processes and personnel to drive strategic outcomes for multiple lines of business
Monitor and ensure the health plan’s execution of meeting or exceeding all appropriate requirements by federal, state, and Accrediting bodies
Responsible for translating business/program vision and strategy into operational tactics to meet market and enterprise goals
Develop health plan policies, procedures and goals as needed to align with the market requirements and CareSource strategy/model
Develops & manages budget if applicable
Supports and leads cost saving initiatives for the health plan
Participate and represent CareSource internally and externally with speaking engagements, State and regional committee work
Advocate for the populations and health plan at state and federal agencies as needed
Conduct an annual evaluation of provider incentives, PMPM cost, etc. outlining the effectiveness of the health plan, develop and create monitoring activities to improve effectiveness of the health plan
Perform any other job related instructions as requested

Requirements

Education / Experience:
Bachelor’s degree or equivalent years of relevant experience is required
Master’s degree in nursing, business, healthcare management, public health, public administration, or associated field is preferred
A minimum of five (5) years of Managed Care Experience is required
Experience with provider education/facility is required
A minimum of five (5) years of Coding Experience is preferred
Working knowledge of Government-regulated (federal and/or state) health insurance products including Medicaid is preferred

Required Competencies / Knowledge / Skills
Demonstrated ability to lead in a matrixed environment to successfully execute strategic and business plans, focusing on cost reductions
Knowledge of clinical guidelines (Milliman/MCG) preferred
Knowledge of coding preferred
SharePoint experience
Clinical data analysis
Knowledge of managed care industry, trends, and accreditation
Knowledge of quality improvement & programs/outcomes measurement
Ability to work independently and within a team environment
Critical thinking skills and strong interpersonal skills
Training/teaching skills
Proven track record in driving continuous improvement based on case reviews

Licensure / Certification
None

Working Conditions
General office environment; may be required to sit/stand for long periods of time

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer, including disability and veteran status. We are committed to a diverse and inclusive work environment.
Contact the job poster
Karen Borgert 2nd

Master of Business Administration – MBA

Job Poster LocationDayton, Ohio

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Seniority Level
Director
Industry
Insurance
Financial Services
Hospital & Health Care
Employment Type
Full-time
Job Functions
Consulting
Information Technology
Sales