Clinical Care Lead

Horizon Blue Cross Blue Shield of New Jersey•Hopewell, NJ

About The Position

This position is accountable for providing guidance and support to the Dual Special Needs Program (DSNP) Clinical Care Coordinators who perform outreach, and ongoing member contact as well as the clinical care managers who manage the Level 1 members. This position also ensures facilitation of health care services within a member centric plan of care, care gap closure and STARS measures performance under the guidance of the DSNP supervisor.

Requirements

High School Diploma/GED required.
Requires a minimum of two (2) years healthcare industry experience.
Requires a minimum of one (1) year experience in a managed care setting.
Requires knowledge of the standards of practice for care managers, coordination of services, and delivery of services.
Requires strong knowledge of managed care principles and concepts including Health Plan Effectiveness Data and Information Sheet (HEDIS) and STARS.
Requires strong organizational skills.
Requires strong oral and written communication skills.
Requires good PC skills, knowledge of working with a Medical Management system for electronic medical records and the ability to utilize Microsoft Office applications (Excel, Access, Word, etc.)
Requires good problem solving and conflict resolution skills.
Requires good presentation skills.
Requires ability to work with limited daily supervision.

Nice To Haves

Preferably with the elderly frail population.

Responsibilities

Oversee, develop and coach staff on process, practices and procedures; develop and monitor goals; contribute to annual performance reviews.
Be a subject matter expert on the DSNP program, and provide staff with instruction and support on it.
Provides telephonic care management assistance for activities specific to the DSNP case management.
Ensure timely member follow up.
Interacts and communicates effectively with the member during telephonic contact.
Perform Clinical Care outreach duties as assigned, carry a caseload / county.
Assist with implementation and facilitation of services for DSNP members.
Interacts with the DSNP member/family, physician and healthcare team.
Utilizes the care plan process to set priorities, plan, organize, and document interventions that are goal directed and member centric.
Documents accurately and comprehensively based on the standards of practice and current organization policies and workflows.
Run reports to monitor compliance on scheduled services / productivity metrics to ensure timely delivery of services and required follow up in accordance with the model of care.
Participate in development of business requirements and user acceptance testing for program enhancements.
Performs other duties as assigned by management.