Anthem, Inc. Manager I Healthcare Management / Utilization (Outpatient) Medicaid in Houston, Texas
SHIFT: Day Job
Your Talent. Our Vision. At Amerigroup , a proud member of the Anthem, Inc. family of companies focused on serving Medicaid, Medicare and uninsured individuals, it’s a powerful combination. It’s the foundation upon which we’re creating greater access to care for our members, greater value for our customers and greater health for our communities. Join us and together we will drive the future of health care.
This is an exceptional opportunity to do innovative work that means more to you and those we serve.
Manager l HCMS/Utilization Management (Outpatient) – Texas Medicaid (PS51645)
Location: Must reside in the state of Texas and be within commuting distance to one of the following office locations:
Grand Prairie, TX
The Manager I HCMS (Texas Medicaid) is responsible for managing a team of physical and/or behavioral health practitioners responsible for coordinating member service, utilization, access, care management and/or concurrent review to ensure cost effective utilization of health, mental health, and substance abuse services for one or more member product populations of varying medical complexity ensuring the delivery of essential services that address the total healthcare needs of members. Primary duties may include, but are not limited to:
Manages and oversees team responsible in case finding and coordinating cases that involve comorbid conditions.
Coordinates service delivery to include member assessment of physical and psychological factors.
Responds to member, provider, and state complaints and inquiries.
Partners with providers to establish short and long-term goals that meet the member’s needs, functional abilities, and referral sources requirements.
Identifies members with potential for high-risk complications.
Reviews benefit systems and cost benefit analysis.
Evaluates medical, mental health and substance abuse service for cost containment.
Supports program compliance and assists in identifying opportunities to improve the customer service and quality outcomes.
Attends state meetings, implements state changes.
Supports quality initiatives and activities, including adherence to National Committee for Quality Assurance (NCQA) standards and HEDIS reporting.
Hires, trains, coaches, counsels, and evaluates performance of direct reports.
Requires a BA/BS; 5 years of experience in Health Care Management; or any combination of education and experience, which would provide an equivalent background.
Current active unrestricted RN license in the state of Texas required.
MSN, MPH, MPA, MSW or MBA with Health Care Concentration preferred.
Certified Case Manager Certification preferred.
Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.
Prior managed care experience strongly preferred.
Knowledge of Interqual criteria and Milliman Care Guidelines required and/or knowledge of Texas State Medicaid criteria (TMPPM.)
Experience leading a team.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
High level of proficiency MS Word, Outlook, Excel required.
Experience using ACMP, HIP (Health Information Platform) and/or Care Compass a plus.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) + match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For® , is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.