Position Summary
Reporting to the Chief Clinical Officer, you will serve as the health plan's clinical point of contact for complex care coordination, care navigation, utilization management, and case management escalations. Working within a managed care environment that partners with delegated clinical vendors, you will act as a key liaison between the health plan, vendor clinical teams, and internal stakeholders to help resolve member care concerns and support a seamless healthcare experience.
As the first person to serve in this role, you will have a unique opportunity to help define and build the health plan's clinical escalation and care navigation function. You will leverage your clinical expertise and managed care knowledge to assess escalated situations, identify barriers to care, coordinate appropriate next steps, and facilitate resolution of complex or high-visibility member issues. You will collaborate closely with customer experience, sales, employer groups, brokers, provider relations, network, compliance, and operational teams to navigate challenges related to care management, provider access, transitions of care, and utilization management services, while helping establish best practices and processes for the future.
Success in this role requires strong clinical judgment, exceptional communication skills, and the ability to effectively coordinate across multiple stakeholders while maintaining a member-centered focus. The ideal candidate is an experienced RN who thrives in a collaborative environment, enjoys solving complex problems, and is excited by the opportunity to build, influence, and improve how the organization supports members with complex care needs.
Essential Job Functions
In this role, you will be responsible for:
Clinical Escalation Management
- Serve as a clinical resource and subject matter expert to internal stakeholders regarding managed care processes, care coordination workflows, utilization management practices, and member navigation challenges.
- Serve as the health plan's clinical point of contact for complex care coordination, care navigation, and member care escalations.
- Assess escalated cases to determine clinical context, urgency, barriers to care, and appropriate next steps.
- Manage urgent, complex or high-profile member issues involving utilization management, care management, provider access, transitions of care, benefits, and healthcare navigation.
Vendor Partnership & Care Coordination
- Partner with outsourced utilization management and case management vendors to facilitate timely resolution of escalated member concerns and ensure appropriate care coordination activities occur.
- Monitor vendor responsiveness, follow-through, and resolution outcomes, escalating concerns as appropriate to vendor leadership and internal stakeholders.
- Work with internal and external stakeholders to implement coordination of vendor processes and projects.
- Coordinate with internal departments including Customer Experience, Provider Relations, Compliance, Quality, Operations, and Medical Management to support effective issue resolution.
Clinical Risk Identification & Escalation
- Identify clinical, quality, access, compliance, privacy, grievance, or member safety concerns and ensure timely escalation to appropriate clinical or operational leaders.
- Recognize high-risk or urgent situations requiring involvement of vendor clinical teams, Medical Directors, Behavioral Health, Compliance, Quality, or executive leadership.
Reporting, Analysis & Continuous Improvement
- Maintain accurate documentation of escalations, interventions, communications, and outcomes in accordance with HIPAA, regulatory, and organizational requirements.
- Analyze escalation trends, member barriers, and vendor performance issues, recommending process improvements that enhance care coordination, member experience, and operational effectiveness.
- Recommend improvements to workflows, vendor handoffs, internal scripts, documentation templates, and service-level expectations.
- Draft internal policies and procedures as needed.
To be successful in this role, you must have:
- A bachelor’s degree or any equivalent combination of education, training, and experience.
- A current, unrestricted Registered Nurse (RN) licensed to practice in Texas.
- At least 4 years of experience in managed care utilization management, case management, care coordination, clinical operations, complex care navigation or any equivalent combination of education, training, and experience.
- Experience working with delegated clinical vendors and managed care partners, including vendor oversight, escalation management, service issue resolution, or clinical operations support.
- Strong understanding of managed care processes, including utilization management, care management, care transitions, provider access, appeals and grievances, and delegated service models.
- The ability to assess clinical situations, identify risks and barriers to care, determine appropriate escalation pathways, and coordinate resolution across multiple stakeholders.
- Experience supporting commercial health plans, employer-sponsored health plans, and/or self-funded employer groups.
- Working knowledge of NCQA, URAC, CMS, HIPAA, state insurance regulations, and healthcare privacy requirements.
- Excellent communication, relationship management, documentation, organization, and problem-solving skills.
- The ability to independently manage multiple priorities while maintaining attention to detail and follow-through in a fast-paced environment.
Benefits
- Automatic 4% employer contribution to retirement plan
- 401k plan with 100% match up to 6%
- Flexible time off for vacation, illness, etc.
- Nine paid holidays
- Day one health, Rx, vision, and dental insurance
- Life and disability insurance
- Flexible spending account
- Pet coverage and pet Rx discounts
- Free identity theft protection
- Free 2nd medical opinion service
Location
Texicare offers a flex-hybrid environment centered around collaboration and connection. All employees must reside in Texas. Team members living in the Austin area are expected to work from our office at least two days per week. Those based outside the greater Austin area may work remotely within Texas, with occasional travel to Austin as needed.
Texicare is an equal opportunity employer.