Dir Government Medical Programs

At Blue Cross and Blue Shield of Nebraska, we are a mission-driven organization dedicated to championing the health and well-being of our members and the communities we serve.

Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there's no greater time for forward-thinking professionals like you to join us in delivering on it!

As a member of Team Blue, you'll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community.

BCBSNE is happy to offer four work designations for our Omaha area employees: 100% in-office, Hybrid options, and 100% remote. If choosing to work remote, this role can be located in one of the following states: Florida, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and Texas.

This position is a key partner in developing and implementing strategies to ensure efficient and effective performance of government medical programs including ACA and Medicare Care Advantage Care Management. This role will collaborate and work closely with the market segment leaders for ACA and MA business. The incumbent will provide leadership in developing initiatives to improve the safety, efficiency, effectiveness and accessibility of care and services provided to members, improve population health, and reduce per capita cost of care. Responsibilities will include ensuring regulatory, accreditation and association requirements are met as they pertain to the organization's government programs and other mandated improvement activities. There will be a strong focus on current trends, evidence, and models to advise and determine appropriate strategic priorities. This position works closely with the medical, pharmacy, product, marketing, claims, network, and service teams to deliver innovative medical management programs and remain compliant with regulatory standards (URAC, CMS, Federal/State requirements). In addition, this individual will establish productive relationships with provider community across the state. The relationships assist in facilitating optimal care delivery, population health management, and high-quality care for our members. This role serves as an expert leader to provide guidance and direction, and strategic transformation in the coming years for the nursing staff and external partners.

What you'll do:

• Advise senior leaders in the development of departmental and organizational strategy and progress toward goals, as well as changes and trends in the internal and external environment that may significantly impact strategic direction, stakeholders, or the future of the enterprise.
• Foster the development of a high performing teams through talent recruitment, cultivating career development plans, coaching performance objectives, communicating strategic direction and managing merit and incentive programs.
• Facilitate a positive work environment that fosters and supports ethical decision making, innovation, customer focus, respect, trust, and collaboration by promoting and modeling the organization's core values.
• Act as an advisor and engage with other teams within the organization to lead the development and execution of improvement initiatives and strategies.
• In conjunction with the Chief Medical Officer (CMO), will develop key strategic goals for medical management programming and will work with internal and external resources to ensure continued compliance with accreditation standards (URAC), CMS and regulatory (Federal/State) requirements.
• Oversee teams responsible for utilization management, case management and appeals. Set clear goals, priorities, and hold team members accountable for delivering on key projects.
• Responsible for integrating medical and policy strategies, programs, and products to support improving member care.
• Collaborate with providers, and affordable care organizations (ACOs) in coordinating medical management (preauthorization/precertification) programs/use of tools into their practices and provider strategic transformation in this process.

To be considered for this position, you must have:

• Bachelor's degree in business or a related field of study or equivalent experience
• Minimum of 7 years' experience with a health care payor, medical management programs or a related field
• Experience leading teams and implementing strategies
• Demonstrated previous experience working in Medicare Advantage and Managed Care Organizations
• This position requires a minimum of 5% travel per month

An equivalent combination of education and experience may be substituted for this requirement.

The ability to meet or exceed the attendance and timeliness requirements of their departments.

The ability to work well in a team environment and be capable of building and maintaining positive relationships with other staff, departments, and customers.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and or ability required.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Other duties may be assigned.

Learn more about what makes BCBSNE such an exceptional place to work by visiting NebraskaBlue.com/Careers.

We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members.

Blue Cross and Blue Shield of Nebraska is an Equal Opportunity /Affirmative Action Employer - Minorities/Females/Disabled/Veterans