Mgr, Post Service Clinical Claims Review

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

About The Position

About the Role About the Role This position is responsible for the design, development, coordination, implementation and outcomes of Plan Medical and Reimbursement Policy, Clinical Coding, Post-service Claims Reviews and Appeals, development, expansion and application of all Departmental Analytic Tools, and oversight of Special Projects spanning all Horizon Commercial, Medicaid and Medicare products. Areas of responsibility cross multiple disciplines including Clinical, Clinical Coding, Operations, Configuration, Primary and Secondary Editing, Communications, Pharmacy Management, Legal, Quality Management, and Payment Integrity. This role continually assesses opportunities for performance and quality improvement through Direct Medical Cost Savings, Administrative Cost Savings both through optimizing operational efficiency and automation via our platform integration, application of Artificial Intelligence, modification of our Evidence Management Module (EMM), and integration of our Claims Policy teams with Claims Policy Operations What You'll Do What you will do

Requirements

Requires High School Diploma/GED
Bachelor’s degree from an accredited college or university preferred
Bachelor's degree preferably in Nursing or related Clinical Healthcare related field) or five to ten (5-10) years of relevant experience.
Requires a minimum of ten (10) years of experience in healthcare and clinical operations or relevant field with an emphasis on delivering clinical programs/health solution interventions to clients in the healthcare industry.
Requires a minimum of five (5) years supervisory experience.
Experience managing multiple projects and complex programs involving cross functional teams required.
Requires a minimum of ten (10) years management experience in healthcare management, clinical coding, and operations.
Requires five (5) years experience in complying with regulatory standards such as NCQA and CMS regulations.
Additional licensing, certifications, registrations: CPC, Change processes e.g. Six Sigma, Lean Sigma Six, Accelerating Implementation Methodology, Continuous Quality Improvement)
Active Unrestricted RN License Required.

Responsibilities

Directs and manages the operational functions within Post-service Claims Reviews, Clinical Coding, Reimbursement Policy, Departmental Analytics, and our Clinical Inquiry Team for all Horizon Commercial, Medicaid and Medicare products, and Special Projects and Initiatives.
Provides leadership to the above teams emphasizing process improvement, implementation, performance and quality improvements through the objective measurement and monetization of activities performed within this Department.
Build relationships with internal and external partners and vendors to collaboratively identify performance improvement opportunities and operational efficiencies.
Oversee the coordination, development and implementation of Clinical Coding and integration into Medical and Reimbursement policies.
Leads in quality initiatives and activities and the generation of data to guide the informed management and leadership of the Medical Policy Department.
Develops and leads Medical Policy Department performance and quality evaluations.
Implements and monitors departmental performance and quality.
Ensures and responsible for the timely identification of problems and correction of deficiencies in accordance with regulatory requirements.
Participates with internal committees in the development of policy and processes to optimize overall performance.
Ensures staff meets all regulatory requirements and comprehends and complies with best practices, professional standards, internal policies, and procedures.
Ensures that staff complies with laws, regulations and policies, and takes reasonable steps to ensure that staff members know and understand the laws, regulations and policies that pertain to the organizational unit's business and takes reasonable steps to assure that staff members conform their actions accordingly.
Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.
Provides regular timely reports on program status to the leadership team.
Participates in special projects as assigned by ACMO.