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Posted: 03-Oct-25
Location: Temple, Texas
Categories:
Internal Number: 25017148
JOB SUMMARY
Dir Health Service Operations is responsible for planning, directing, and managing the delivery of health services by participating providers of the health plan of Baylor Scott and White Health (BSWH). Directs and conducts assessment activities that evaluate the appropriateness, efficiency, and cost-effectiveness of services provided by the health plan in Utilization Management. Designs and establishes health services policies, methodologies, procedures, criteria, and guidelines to ensure effective utilization review and management that delivers appropriate patient care coordination of resources and meets all relevant Regulatory and NCQA requirements. Partners with medical staff to develop and implement efficient utilization programs that result in the most positive medical outcomes in the most cost-effective manner. Identifies, analyzes, and reports on significant utilization trends, patterns, and impacts to the health plan and services delivered. Designs, analyzes and communicates reports, metrics, and documentation on utilization performance indicators and NCQA accreditation and compliance requirements. Consults with physicians to develop improved utilization of appropriate patient care services. Ensures compliance with all legal, accreditation and regulatory requirements and responsiveness and implementation of changes in requirements. Leads oversight of external vendor or contractor management that perform some of the utilization review functions on behalf of the healthplan. Coordinates with medical, clinical, and other BSWH departments to ensure health plan services for members are necessary, timely, and cost-effective.
An entity Director translates and implements strategic plans and objectives for area of responsibility. Makes decisions on operational matters and ensures achievement of objectives. Recommends organizational changes for area. Plans and executes projects and initiatives that meet annual objectives. Plans and directs the operations of a department or area, with responsibility for staffing, processes, budgets, and costs of the unit. Leads and advises subordinate(s) to meet schedules, resolve technical problems, and monitor performance. Has a larger, more complex organization or functional area than a manager. Has multiple managers reporting to the role.
ESSENTIAL FUNCTIONS OF THE ROLE
1. Directs the Utilization Management department for the BSWH health plan.
2. Recommends and implements strategic and operational plans and priorities for health services aligned to BSWH overall business objectives.
3. Directs the prospective, concurrent, and retrospective utilization review for health services delivered by providers through the health plan.
4. Reviews defined metrics to validate program effectiveness and evaluation and ensures appropriate resources are assigned to meet needs.
5. Collaborates with departments across product lines to identify opportunities to improve quality of care, reduce administrative cost, and improve service delivery.
6. Develops, implements, and revises the utilization management policies, procedures, operational guidelines, and process workflows.
7. Leads operational improvement initiatives, programs, and special projects with an emphasis on improved healthcare cost and quality.
8. Selects and leads vendors delegated to perform specific operations and ensures deliverables meet service contract.
9. Designs and implements dashboards, metrics, and reporting which will provide accurate assessment of utilization management performance including key performance measures which assess the effectiveness of communication, general cost, and utilization trending.
10. Ensures compliance with requirements for all regulatory, contractual and accreditation requirements related to utilization management health plan services.
KEY SUCCESS FACTORS/Qualifications
1. Bachelor?s degree in business, finance, or related field preferred.
2. 5+ years of experience in Health plan utilization management in a leadership role
3. Knowledge of health plan utilization management regulations in Texas and in the federal government.
4. Experience managing an organization of over 50 staff.
5. Knowledge of managed care concepts.
6. Knowledge and experience managing NCQA accreditation standards.
7. Ability to work cross-functionally within a highly matrixed environment, with effective collaboration across the organization.
8. Excellent verbal, written, and presentation skills.
BENEFITS
Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level
QUALIFICATIONS
- EDUCATION - Bachelor's or 4 years of work experience above the minimum qualification. Bachelor's degree in business, finance, or related field very highly preferred.
- EXPERIENCE - 3 Years of Experience, 5+ years in health plan utilization management in a leadership role very highly preferred.