Director II Under the limited direction of the lead Director for Utilization Review (UR), in the Office of the Medical Director, Medicaid and CHIP division, this position serves as the Assistant Director for Managed Care UR units. The position performs advanced senior-level managerial work coordinating and overseeing the activities for the daily operations of assigned agency functions and for directing the strategic operations and planning functions for the section. The position oversees the managed care utilization review functions involving daily operations which support the managed care utilization review units. This position directly supervises a manager whose unit is responsible for development and provision of training to UR staff; development and maintenance of internal standard operating procedures; project management of special assignments, projects, and tracking of corrective action plans and reviews and UR operational oversight; Legislative assignments; written reports; review tool and instruction development/maintenance; and general operational policies and procedures. The managed care UR section conducts thorough investigations of managed care organizations (MCOs) in various Medicaid managed care products, including STAR+PLUS, STAR Kids, STAR Health, and STAR for both acute care and long term services and supports. UR also conducts reviews of services in waivers serving individuals with intellectual and developmental disabilities, hospice and other fee-for-service Medicaid programs. The Assistant Director for Managed Care UR also assists the lead UR Director in special assignments; is a liason with other UR units; attends meetings with internal divisions and external stakeholders; and ensures UR operations effectively support the UR units. The UR Assistant Director oversees the development of a work plan, processes, and protocols to guide conducting utilization reviews. Directs staff in compiling and analyzing data to support findings collected from reviews of MCOs and service providers to determine outcomes for individuals receiving Medicaid services. This position provides direction and guidance in strategic operations and planning to achieve the goals and objectives for utilization review with a priority focus on cases with the highest health and fiscal risk. Work involves establishing the strategic plan and goals and objectives; developing policies; reviewing guidelines, procedures, rules, and regulations; establishing priorities, standards, and measurement tools for determining progress in meeting goals; coordinating and evaluating program activities; reviewing and approving budgets; recommending and implementing process improvements; and represents the agency at meetings and conferences. Plans, assigns, and supervises the work of others. Works under minimal supervision, with extensive latitude for the use of initiative and independent judgment.
Essential Job Functions:
Ensures through utilization review (UR) efforts that Medicaid and CHIP managed care programs are delivered efficiently and effectively and are in compliance with federal and state laws, regulations, policies and HHSC rules. 20% • As determined by the Lead Director for Utilization Review, directs, manages, hires and develops professional and management staff for designated Managed Care Utilization Review units. Provides effective direction and leadership to designated staff within the Utilization Review team and holds them accountable for achieving performance expectations, stated program goals and legislative mandates. 20% • Acts as the assistant director for managed care utilization review by supporting the lead director in Medicaid managed care oversight efforts led by the managed care UR units, and acting as the clinical lead for Utilization Review activities. 15% • Represents the agency at business meetings, hearings, trials, legislative sessions, conferences, and seminars or on boards, panels, and committees. 10% • Develops program goals, strategies and initiatives to align with Medicaid and CHIP, and HHSC strategic plan. 10% • Assist in the development of HHSC legislative appropriations requests, federal funding requests and grant requests to ensure adequate support and funding for UR functions. Develops and manages departmental budget and HHSC resources efficiently and effectively. 10% • Develops and implements techniques for evaluating program activities, and reports findings and recommendations for improvements to executive staff. 10% • Provides effective communication to include: keeping the Lead UR Director, Medicaid and CHIP Medical Director, and other OMD/UR staff informed of program issues, communicating program goals, objectives and changes to program staff, establishing and maintaining effective working relationships, and responding to requests for information in a timely manner. 5%
Knowledge Skills Abilities:
Ten years of experience in managing and directing complex programs of which four years should be in an executive or senior management capacity. Prefer experience in governmental or non-governmental experience with public health programs. Knowledge of the role of federal and state laws, regulations, policies, and procedures in management of publicly funded health care services. Knowledge of the State of Texas legislative process. Ability to develop and implement strategic plans, goals, objectives, and evaluation tools to monitor progress and ensure accountability. Ability to monitor and direct multiple interrelated projects and initiatives through appropriate project/program management techniques. Ability to effectively manage employees; i.e. recruit, hire, develop, performance management, ensure accountability, and motivate to build morale. Skill in the application of risk management strategies including the ability to routinely identify, manage and effectively mitigate risks. Knowledge of quality assurance oversight functions in a business environment. Ability to facilitate effective issue resolution through dialogue, alternative analysis and consensus building techniques. The ability to communicate effectively, build and maintain effective working relationships, negotiate with individuals and groups internally and externally, develop professional networks with other organizations, and to identify the internal and external dynamics that impact the work of the organization. Ability to work collaboratively with other divisions of the enterprise on procurements and contracts. Ability to effectively oversee outsourced projects including approval of project timelines, deliverables, implementation and operations as well as the vendor performance required under the contract.
Registration or Licensure Requirements:
Registered nurse (RN), advanced practice registered nurse (APRN), or nurse practitioner (NP), an applicable State of Texas license in good standing is required.
Initial Selection Criteria:
Management of complex programs. Experience with Medicaid Managed Care. Experience in a leadership role in a clinical setting or a role with a clinical focus.
No direct military equivalent
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