OverviewThe Manager-HCS Business Operations will develop and lead a cross-functional team to ensure consistent benefit interpretation across the organization. They will be responsible for identifying necessary changes in medical and administrative policy and drafting them for approval by a Medical Director, then overseeing the implementation throughout the organization (systemically, procedurally and communicated). In addition, they will be responsible for identifying recommended changes to the Prior Authorization program and seeking approval from Medical Directors and Medical Managment to lead implementation throughout the organization which includes balancing use of services on traditional PA, services off PA and services on automated PA. The Manager will ensure accurate system configuration and appropriate benefit administration that demonstrates alignment between member contracts, regulatory requirements, provider reimbursement policies and medical policy. The Manager will work collaboratively with and influence multiple departments to continually assess and make recommendations for improvements to maintain an effective and efficient utilization management process, as well as manage medical expenses based on trends. They will maintain pre-authorization requirements, obtain reporting to understand utilization trends and cost, recommend changes to Healthcare Services Clinical and Operations leadership and ensure implementation of any changes approved. The Manager will be responsible for reporting, analyzing and communicating recommendations on savings opportunities and/or impacts from team activities to senior leadership.QualificationsBachelor’s degree required. Master’s degree preferred. An additional four (4) years of experience will be considered in lieu of degree.Registered Nurse (RN) with active, unrestricted NYS license preferred.Certified Professional Coder (CPC) is highly preferred.Five (5) years of experience in health plan managed care operations required.Two (2) years of progressive leadership and/or management responsibility required.Functional knowledge of clinical care management processes, member benefit structures and applications and claims processing required.Prior experience with Claims Systems, Clinical Platforms and/or CRM applications is preferred.Ability to define problems, analyze data/information and critically think through scenarios.Knowledge and experience in development of processes and SOPs.Excellent verbal, written and interpersonal communications skills required with emphasis on diplomacy, negotiation, persuasiveness and interaction with multiple levels of management.Ability to work independently and lead or participate on multi-disciplinary project teams.Excellent time management and organizational skills.Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative and Accountable.Essential AccountabilitiesStay abreast of new clinical technology, treatments, testing and trends in the market to ensure medical and administrative policy is current and competitive within industry.Optimize existing policy as it relates to medical management and utilization management by monitoring what is on prior authorization and making changes (add/remove) as needed.Monitor utilization trends and clinical appropriateness and make changes (add/remove) in services or suppliers as needed related to effectiveness of the Gold Card and Post Service Pre-Payment (PSPP) programs.Develop and lead a cross-functional team (including Claims, IT, NCM, HCS, Servicing, and Product) to ensure consistent benefit interpretation across the organization.Oversee and ensure accurate system configuration and appropriate benefit administration to demonstrate alignment between member contracts, regulatory requirements, provider reimbursement policies and medical policies.Work collaboratively with multiple departments to continually assess and make recommendations for improvements to maintain an effective and efficient utilization management process and manage medical expenses based on trends.Analyze utilization trends and costs and communicate recommendations and potential savings/impacts to HCS leadership.Manage and support HCS team with regards to implementation and communication (internal and external) of new medical management processes.Work collaboratively with training resources to ensure all medical management staff are updated on new product changes and impacts to functions.Develop processes for the creation, tracking, and reporting of all benefit management changes within the medical management department.Maintain pre-authorization requirements and ensure implementation of any approved changes.Maintain preventative list as designated by government entities.Assist in medical management policy and SOP development.Provide application systems expertise to client communities.Participate in the Provider Communications team and others as designated as the HCS department representative.Hiring Compensation Range: $90,000 - $110,000 annuallyCompensation may vary based on factors including but not limited to skills, education, location and experience. In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off. The base salary range is subject to change and may be modified in the future.As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant’s race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law. 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Minimum Salary: 90000 Maximum Salary: 110000 Salary Unit: Yearly