Sr. Director Government Medical Programs

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.

• 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.

• 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 building and leading teams and implementing strategies
• Experience mentoring and coaching leaders
• Demonstrated previous experience working in Medicare Advantage and Managed Care Organizations
• Prior Medicare Advantage medical management and utilization management experience at a leadership level (Director-level or above)
• Demonstrated experience delivering business results
• Experience with data-driven decision making
• Regular travel to Omaha required
• Ability to work in a fast-paced, dynamic environment