Health Plan Manager
Hyde Park Campus
2010053 BSD Senior Administration
About the Unit
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. This position is responsible for:
- Daily administrative management and vendor relations (Aetna and Caremark) of the University of Chicago's Health Plan (UCHP) a self-funded health insurance plan
- Enable efficient operations by monitoring enrollment, utilization, case management, member services, claim processing, provider and customer relations
- Implement, coordinate, optimize, and align the UCHP-related strategies and activities for the Hospitals, BSD and their affiliates
- Serve as a system-wide subject matter expert of the self-funded plan, administering policies, provide guidance on plan options and overseeing the resolution of issues with a full understanding of internal and external practices and procedures
- Collaborate with colleagues from diverse disciplines and external business partners in a complex organizational structure to create a vision and strategy for plan enhancements based on the plan population, organizational priorities and health care practices
- Resolve complex issues using creative and effective professional concepts and enterprise-wide program objectives
- Work on complex issues with little or no precedent where analysis of situations or data requires an in-depth evaluation of variable factors
- Exercise judgment in selecting methods, techniques and evaluation criteria for obtaining results
- Responsible for managing the existing TPA (Aetna) and pharmacy benefit manager (Caremark) relationships including the general administration, operations, financial well-being, policy development and implementation for UCHP. Provide ongoing analysis and evaluation of plan costs and trends
- 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 the plan
- Oversees financial monitoring including out of-network cases. Monitor system-driven reimbursement payment methodologies to meet proper, accurate, and timely payment. Manages and provides oversight for the plan's medical, actuarial and cost of care data analytics. Ensures routine actuarial determinations of plan premiums and IBNR
- 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
- 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 coordinating and implementing plan
- Formulates, builds, and establishes objectives and strategic plans with other high level managers to proactively address key program and legislative issues. Acts as a key team member in the strategic planning process
- Employs strategic and analytical thinking, strong capability of project management and problem solving skills, sound judgment and a willingness to resolve issues and problems in a timely manner impacting overall plan efficiency, member experience and plan financials
- 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 ensuring that the program tracks to set resources/budget, scope, and timeline and facilitating accountability by elevating issues to appropriate leadership
- Excellent collaboration and relationship building skills, including influencing without authority
- Capability to apply political acumen to intricate situations occurring in complex, organizational structures
- Able to establish and maintain trust, confidence, and effective working relationships with colleagues and individuals of diverse occupational and social background
- Aptness to principles and practices required to develop, implement, and evaluate health and welfare benefit programs
- Ability to use strategic thought and independent judgment to develop solutions reflecting the legal, policy, and operational needs of the organization
- Apply initiative, resourcefulness and creativity in problem-solving
Education, Experience or Certifications:
- Bachelor's degree required
- Master's degree preferred
- 5+ years of experience in medical insurance, HMO Administration, claims adjudication and/or hospital billing required
- 5+ years of experience in management including budget responsibility and financial reporting/monitoring required
- 5+ years of supervisory experience within a managed care operations environment with understanding of reimbursement, capitation and managed care schedules required
- Knowledge of current principles and procedures of fully-insured and self-insured/self-funded health plan administration
- Previous experience with Medical Management functions in the Managed Care industry; specifically utilization and quality management
- Experience performing utilization review and case management activities in a health care setting preferred with sufficient independence and sound judgment
- Knowledge and experience in managed health care operations
Technical Knowledge or Skills:
- Ability to use EPIC or a computerized billing system required
- An understanding of Total Quality Management principles required
- Strong organizational skills with demonstrated ability to manage multiple projects and meet deadlines required
- Ability to lead and pursue projects independently while exercising good judgment and exhibiting a considerable degree of creativity required
- Concise/precise verbal and written messaging and executive level presentation material design skills required
- Comprehensive working knowledge of Windows and the Microsoft Office suite including word-processing, spreadsheet applications, project management and database programs required
- Cover Letter
- Reference Contact Information
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.
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