Job Description

Overview

The HMO Director will oversee all aspects of HMO operations, including billing, case management, utilization management, provider relations, and regulatory compliance. This role requires a strategic leader capable of driving operational efficiency, ensuring member satisfaction, and aligning departmental performance with organizational goals.

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Key Responsibilities:

Lead and manage all HMO operations, including billing, authorizations, case management, and claims processing. Develop and oversee departmental strategies, budgets, and performance metrics to ensure operational efficiency. Ensure full compliance with federal and state regulations, including Medicare, Medicaid, and commercial HMO requirements. Collaborate with clinical, provider, and administrative teams to improve care coordination and member outcomes. Oversee provider contracting, credentialing, and network maintenance. Monitor key performance indicators, identify trends, and implement process improvements. Lead, mentor, and develop a high-performing team of HMO professionals. Represent the organization in audits, payer meetings, and regulatory reviews.

Qualifications:

5+ years of senior-level experience in HMO/managed care operations, preferably in billing, case management, or utilization management. Proven leadership experience managing multi-disciplinary teams. Deep knowledge of Medicaid, Medicare, and commercial HMO processes and regulations. Strong financial acumen and experience managing budgets. Excellent analytical, problem-solving, and strategic planning skills. Effective communication and negotiation abilities with providers, payers, and internal leadership. Bachelor's degree in Healthcare Administration, Nursing, Business, or related field.
Job Type: Full-time

Pay: $120,000.00 - $175,000.00 per year

Work Location: In person