Supervisor, Clinical Ops

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

About The Position

The position is responsible for leading a specific clinical care team in a hands-on manner to provide exceptional service to the customer and contain medical claims cost. This is accomplished through active involvement and leading of the day-to-day operations of a clinical care team and ensuring staff is consistent with Horizon's policies and procedures and are compliant with contractual, state and federal guidelines. Serves as a medical resource to members and providers, as well as non-clinical staff.

Requirements

Requires a Nursing degree or a Masters in a Behavioral health related field or a Bachelors in a health related field.
Requires a minimum of two years' full time acute healthcare/direct clinical care experience to the consumer.
Requires a minimum of one year direct supervisory experience or demonstrated supervisory experience leading teams in a matrix management environment.
Requires minimum of 12 months experience in a managed care setting or the health insurance industry.
Active Unrestricted NJ LCSW, LMFT, LPC, or RN/PT License Required
Medicaid Case Management Only: Active Unrestricted NJ LSW, LCSW, LMFT, LPC, or RN/PT License Required
Requires knowledge of Utilization Management (UM) and managed care principles.
Requires knowledge of the Case Management/Disease Management Standards of Practice.
Requires knowledge of health care systems and medical documentation.
Requires knowledge of State Mandates and Regulations.
Requires knowledge of regulatory bodies and their processes.
Requires knowledge of NCQA accreditation standards.
Requires knowledge of community health resources.
Requires the ability to express thought clearly and concisely both orally and written.
Requires the ability to obtain the skills possessed by the team members and system technical competence.
Requires the ability to effectively lead team members in diversified tasks.
Requires excellent organizational skills.
Requires excellent presentation skills.
Requires the ability to think analytically and to report findings in an accurate manner.
Must be proficient in the use of personal computers and supporting software in a Windows based environment including MS Office products (Word, Excel, PowerPoint) and Outlook; should be knowledgeable in the use of intranet and internet applications.
Travel required to other Horizon offices, provider locations and/or for oversight of remotely located workforce members in accordance with Company needs.

Nice To Haves

Prefer certification as a case manager.
Prefer minimum of three years’ experience as a case manager.

Responsibilities

Manages, analyzes and coordinates the daily activities of the unit to ensure departmental productive goals are met with regards to quality timeliness, accuracy and consistency of medical decisions.
Ensures staff meets all regulatory requirements and comprehends and complies with best practices, professional standards, internal policies and procedures.
Conducts continuous evaluation of workflows and seeks to improve processes that impact the department.
Coordinates data collection, reviews compliance reporting and identifies opportunities for improvements.
Identifies and implements cost saving/revenue generating opportunities.
Serves as key liaison between Medical Directors, Management leadership, and staff. Also serves as a medical resource to members and providers, as well as non-clinical staff.
Develops key performance indicators to evaluate level of service for internal and external customers.
Acts as a subject matter expert for difficult and complex matters.
Represents the Plan with external customers, providers and agencies.
Represents the department on internal committees and participates in special projects.
Assists Manager in coordinating regulatory, quality and accreditation activities.
Performs other duties as assigned by management.
Creates and champions an atmosphere within the team, which fosters open communication, teamwork, ownership, and a collaborative cross-departmental environment to implement, optimize and share continuous improvement processes.
Manages, directs, and develops staff by providing feedback and coaching.
Administers performance and salary reviews for staff.
Assists in preparing and monitoring the budget to ensure administrative cost objectives are met.