Dir, Clinical Operations-EDC91

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

Responsible for providing clinical direction and leadership for the integrated clinical operations teams, which include pre-certification, pre-determination, concurrent review, complex case management, and chronic care management. Working in collaboration with the Sr. Medical Director for Medical Management, leads staff in developing, translating and executing Health Affairs and Medical Management strategies and operational objectives with primary responsibility for achieving cost of care goals, quality outcomes, customer satisfaction, ACR goals, and meeting accreditation and regulatory requirements.

• Directs department by providing strategy and related goals to day-to-day managers, ensuring appropriate staffing, overall client satisfaction and appropriate and effective level of service delivery.
• Assures Clinical Operations is effectively integrated to support the implementation and operational effectiveness of the Community Based Care Management operational model.
• Develops annual Medical Management work plan, Annual Medical Management Program Description, Annual Medical Management Program Evaluation, and additional reports as required for meeting accreditation and regulatory requirements.
• Develops and monitors goals for staff and provides ongoing feedback and coaching.
• Conducts performance reviews on an annual basis and administers salaries for the staff.
• Directs the employment activities of the office that include staffing, development, and training.
• Ensures staff meets all regulatory and accreditation requirements and comprehends and complies with best practices, professional standards, internal policies, and procedures.
• Determines departmental budget and conducts ongoing expense management.
• Develops/implements policies and manages clinical services operations to achieve financial efficiencies and clinical effectiveness.
• Identifies operational processes, determines areas for improvement and sets measurement in place to enhance operations, reduce operating cost, standardize best practices and ensure appropriate compliance with quality standards.
• Conducts or directs assessments of clinical services provided to Horizon BCBSNJ members. Identifies and implements strategic initiatives to ensure significant clinical improvements while reducing administrative costs.
• Formulates guidelines around caseload and discharge practices to meet objectives of quality, cost containment and member satisfaction.
• Establishes and achieves ROI targets.
• Provides direction for developing and ensuring implementation of ongoing training programs and procedures to monitor, evaluate and improve overall quality of clinical services and increase customer satisfaction.
• Provides leadership to multiple levels of professional staff while serving as a role model, teacher and coach to clinical professionals.
• Forms strategic operational relationships, particularly with hospitals, health systems, PCMHs, ACOs, and community resources which will support clinical services programs growth and expansion, development of new programs and achievement of program targets.
• Facilitates the establishment of effective and efficient internal and external customer interfaces.
• Works cross functionally and collaboratively with various division/department leaderships to develop strategic initiatives as ongoing improvements.

Education/Experience:

• Bachelors degree in Science or Business required. Masters degree preferred.
• Diversified health care background with 5-10 years experience in managed care.
• Minimum of 5 years Director level/leadership experience.
• Demonstrated operations management experience and results orientation.
• Thorough understanding of managed care principles, models and financing.
• Knowledge of UM, DM, CM and Prior - Authorization.
• High energy with solid clinical experience, in-depth knowledge of the managed care industry.

Additional licensing, certifications, registrations:

• Valid and unrestricted NJ RN, LCSW, LPC, or LMFT license required.

Knowledge:

• 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 Lotus Notes; Should be knowledgeable in the use of intranet and internet applications.

Skills and Abilities:

• Strong leadership, execution and customer (internal/external) satisfaction skills.
• Strong analytical skills to evaluate data from various sources, identify trends and issues and develop recommendations to senior management.
• Innovative