Health Plan Manager
Hyde Park Campus
2010053 BSD Senior Administration
About the Unit
The Biological Sciences Division (BSD) and the University of Chicago Medical Center (UCMC) are managed by a single Dean/Executive Vice President and comprises the largest unit of the University. The Medical Center oversees the finances and operations of all inpatient and ambulatory services. Physicians who provide patient care services are all appointed in one of the 13 clinical Departments within the BSD. The BSD includes the Pritzker School of Medicine, approximately 24 academic units, degree granting committees, and research centers and institutes. The BSD is located on the University's main campus in Hyde Park, ten minutes south of downtown Chicago. BSD's patient care operations are conducted primarily at the University of Chicago Hospital and clinics, which share the same campus. In addition, we launched a network of clinically integrated community physicians.
The University of Chicago Health Plan (“UCHP”) is a benefit option for employees of both The University of Chicago and The University of Chicago Medical Center. Working with the current TPA (Aetna) and pharmacy benefit manager (Caremark), ensure the efficient operation of the University of Chicago's Health Plan (UCHP) by monitoring enrollment, utilization, case management, member services, claim processing, and provider and customer relations. Implement and coordinate the UCHP-related strategies and activities for the Hospitals, BSD and their affiliates.
Serve as a liaison between the Office of Managed Care, the BSD, Hospital Finance, Claims, Customer Service, Admitting, utilization/quality management customers and payers to educate, troubleshoot, investigate and resolve concerns regarding managed care issues. Along with managing the health plan, provide administrative oversight related to utilization case management activities including utilization review, discharge planning, case management, quality improvement and educational responsibilities. Emphasis is placed on advocacy for the health plan member, ensuring appropriate utilization of available resources, financial solvency, and continuity of care and quality outcomes.
- Informs and advises the Dean for Clinical Affairs on financial trends and activities; presents financial information at the Management and Strategy Committee meetings.
- Responsible for managing the existing TPA (Aetna) and pharmacy benefit manager (Caremark) relationships including the general administration, operations, financial well-being, and policy development and implementation for UCHP.
- Provides on-going analysis and evaluation of plan costs and trends; develops reporting systems and processes to monitor and implement any required remediation as appropriate.
- Develop and implement tools for monitoring and evaluating performance objectives, compliance and effectiveness of existing TPA and pharmacy benefit manager.
- Develops and implements a plan for fiscal control including budgeting, general accounting, provider and services contracting and other relevant functions.
- Maintains excellent, collaborative relationships with finance, medical and benefits constituents in the University, the BSD and Medical Center to ensure the proper functioning and orchestration of plan management activities.
- Oversees financial monitoring including out of-network cases.
- Monitor system-driven reimbursement payment methodologies to meet proper, accurate, and timely payment.
- Manages assigned staff and consultants, and provides oversight for the plan's medical, actuarial and cost of care data analytics.
- Ensures routine actuarial determinations of plan premiums and IBNR.
- Develop and maintain awareness of trends, changes, and regulations in the industry and other related health care industries.
- Maintain and periodically review UCHP vendor contracts. Periodically meet with vendors to discuss issues and/or product updates.
- Ensures compliance with all relevant regulatory requirements and related agencies.
- Keep abreast of any state/federal laws or legislation that may affect UCHP terms of coverage. Review, suggest, and provide support for additions, updates, or language changes to UCHP terms of coverage that result from industry trends, member feedback, or substantive changes to the Plan.
- Assist the Office of Managed Care in coordinating and implementing contract terms.
- Act as a liaison between UCPP, University and UCMC Human Resources offices, physicians, departmental administrators, Hospital Finance and Utilization Review Committee, UCMC's Managed Care offices, and primary care site administrators.
- Resolve/troubleshoot issues that cannot be handled by the Managed Care Representatives including but not limited to, a review and approval of member reimbursement requests, terms of coverage interpretations, member complaints, sensitive/high priority member issues, resolution of member billing issues between UCH and UCHP due to UCH billing issues/member identification issues.
- Negotiate and implement direct agreements with providers as needed to supplement existing UCM and AETNA networks, and coordinate with AETNA (or current TPA) on implementation and management of direct provider contracts.
- Coordinate with UCHP Medical Advisors on UCHP care management and quality improvement responsibilities and initiatives internally and in partnership with AETNA (or current TPA).
- Facilitate ongoing status meetings, updates and strategic planning with internal stakeholders, UCHP Medical Advisors, TPA, PBM and other vendor partners.
- Enhance member enrollment and optimize member education and communication, including electronic access.
- Maintain adherence to the terms of coverage.
- Collaboration with the Medical Directors.
- Knowledge and experience in managed health care operations.
- Good organizational and project management skills.
- Strong communication skills, both written & verbal.
- Detailed oriented with good problem-solving skills.
- Proficiency with MS Office, Word, & Excel.
Education and Experience:
- Bachelor's degree required.
- Master's degree preferred.
- Previous experience in medical insurance, HMO Administration, claims adjudication and/or hospital billing required; preferably five years.
- Previous supervisory experience within a managed care operations environment with understanding of reimbursement, capitation and managed care schedules required; preferably five years.
- Previous experience with Medical Management functions in the Managed Care industry; specifically utilization and quality management preferred.
- Previous management experience, including budget responsibility and financial reporting/monitoring required; preferably 5 years.
- Previous experience performing utilization review and case management activities in a health care setting preferred with sufficient independence and sound judgment required; preferably two years.
Technical Knowledge or Skills:
- Solid knowledge of the operations of inpatient and outpatient care facilities required.
- Understanding of reimbursement, capitation and managed care schedules required.
- An understanding of Total Quality Management principles preferred.
- Ability to use EPIC or a computerized billing system required.
- Comprehensive working knowledge of personal computers and word processing, database, and spreadsheet software required.
Working Condition and Physical Requirements:
- Ability to work accurately with attention to detail.
- Ability to work for long periods of time in a sitting position, at a keyboard, viewing computer screen.
- Cover Letter
- References preferred
NOTE: When applying, all required documents MUST be uploaded under the Resume/CV section of the application
Depends on Qualifications
Scheduled Weekly Hours
Job is Exempt?
Drug Test Required?
Does this position require incumbent to operate a vehicle on the job?
Health Screen Required?
Remove from Posting On or Before
The University of Chicago is an Affirmative Action/Equal Opportunity/Disabled/Veterans Employer and does not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national or ethnic origin, age, status as an individual with a disability, protected veteran status, genetic information, or other protected classes under the law. For additional information please see the University's Notice of Nondiscrimination.
Staff Job seekers in need of a reasonable accommodation to complete the application process should call 773-702-5800 or submit a request via Applicant Inquiry Form.
The University of Chicago's Annual Security & Fire Safety Report (Report) provides information about University offices and programs that provide safety support, crime and fire statistics, emergency response and communications plans, and other policies and information. The Report can be accessed online at: http://securityreport.uchicago.edu. Paper copies of the Report are available, upon request, from the University of Chicago Police Department, 850 E. 61st Street, Chicago, IL 60637.
The University of Chicago is an urban research university that has driven new ways of thinking since 1890. Our commitment to free and open inquiry draws inspired scholars to our global campuses, where ideas are born that challenge and change the world.
We empower individuals to challenge conventional thinking in pursuit of original ideas. Students in the College develop critical, analytic, and writing skills in our rigorous, interdisciplinary core curriculum. Through graduate programs, students test their ideas with UChicago scholars, and become the next generation of leaders in academia, industry, nonprofits, and government.
To learn more about the university click here http://www.uchicago.edu/