This job was posted by https://idahoworks.gov : For more information, please see: https://idahoworks.gov/jobs/2192326 Director Member and Provider Appeals

Remote in Washington, Oregon, Utah or Idaho

Primary Job Purpose

Provides leadership for operational areas within Clinical Services including functions such as Medical Management (Prior Authorization and IP Concurrent Review), Member and Provider Appeals, Vendor Management, and Project Implementation. Participates on the Clinical Services Leadership Team and helps drive effective systems and processes, operational reporting, regulatory compliance, and business and clinical results.

General Functions and Outcomes

• Provides leadership in developing, implementing, and communicating short and long-range plans, goals, and objectives. Aligns team goals with the organization\'s vision and strategy, federal and state law and regulations, accreditation standards, and client requirements.
• Develops and implements systems, policies and procedures for areas managed. Analyzes work flows to optimize business process and compliance, identifies system business requirements and continuously improves processes and outcomes.
• 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. Manages quality and successful outcomes of functions or projects.
• Makes recommendations as to the use and selection of external vendors. Provides leadership and operational oversight to vendors, ensuring quality, cost and efficiency goals are attained.
• Partners with leaders across Health Care Services, multiple lines of business, and other functional areas of the organization to develop, lead and oversee clinical operations and related programs.
• Ensures compliance with and participates in legislative initiatives and mandates including but not limited to federal, HIPAA, state mandates and URAC.
• Oversees the production and delivery of high-impact, timely reports that support clinical services and demonstrate the value of clinical programs and services.
• Advocates for effective and efficient technology solutions for clinical services staff and for clinical programs. Provides leadership to develop new process and system capabilities.

Minimum Requirements

• Knowledge of health insurance industry trends and technology including familiarity with clinical program management and related functional and operational areas.
• Demonstrated ability to develop and 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.
• Proficiency with healthcare data, technology, and data reporting systems.
• Demonstrated ability to create and execute operationally efficient and cost-effective 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.
• Familiarity with clinical terminology and data. Direct clinical background or licensure preferred.

Normally to be proficient in the competencies listed above

Director Member and Provider Appeals would have a Bachelor\'s degree in healthcare, business or related field, ten years of experience in a health insurance environment (to include utilization management, clinical intake/customer service, health information management, and/or quality improvement) and five years leadership experience or equivalent combination of education and experience.

Work Environment

Work primarily performed in remote setting.

Travel may be required - locally or out of state.

May be required to work outside of normal hours.

#LI-Remote

The expected hiring range for a Director Member and Provider Appeals is \$159,800 - \$216,200 depending on location, skills, experience, education, and training; relevant licensure / certifications; performance history; and work location. The bonus target for this position is 25%. The current full salary range for this role is \$150,000 - \$245,000.

Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits. In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which w