Director, MLTSS Operations

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

Job Summary:

The Director, MLTSS Operations will be responsible for the oversight and management of the Managed Long Term Care Program. This position will work in collaboration with HNJH internal departments and external providers to ensure the program is meeting all contract requirements This position is responsible for the design, development, implementation, and coordination of MLTSS services and supports, including home and community-based services and Nursing facility services such as Nursing Homes and Assisted Living. The Director will also oversee the non-clinical team supporting the Care Management team with authorization management and provider outreach.

Job Responsibilities:

• Develops and implements the department strategy and related goals for management, ensuring overall member satisfaction and appropriate level of service delivery.
• Responsible for program compliance and the successful coordination, planning, implementation, and evaluations of patient care within the Managed Long Term Care Program.
• Oversees and coordinates the development and completion of member assessments in accordance with NJ State contract requirements, regulations, and accreditation guidelines.
• Directs and ensures Care Coordination in a multitude of care settings.
• Responsible for evaluating the educational needs of clinical care staff and overseeing the development and execution of trainings. 
• Oversees HNJH MLTSS clinical team to ensure effective, efficient, and quality care is being safely delivered to HNJH members.
• Collaborates with internal and external entities on workgroups that facilitate the implementation of new or changing regulations and/or corrective actions.
• Identifies trends negatively impacting operations and engages other departments and stakeholders to identify barriers and work towards process improvement.
• Collaborates with medical economics to ensure timely reporting and outcome management.
• Uses data and collaborates with analytical experts to produce reports that measure performance of population-based initiatives.
• Develop policies and procedures that are in alignment with the State of NJ MLTSS contract that support the HNJH MLTSS Program.
• Collaborate with Provider Contracting and Services Department to ensure adequate LTCSS network for our members.
• Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.

Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Education/Experience:
•    High School Diploma/GED required.
•    Bachelor’s degree preferred or relevant experience in lieu of degree.
•    Requires a minimum of eight (8) to ten (10) years management experience in healthcare management and Medicaid.
•    Requires a minimum of three (3) to five (5) years clinical management experience.
•    Requires a minimum (5) years supervisory experience.
•    Requires experience in complying with NCQA and CMS regulations.

Additional Licensing, Certifications, Registrations:
•    Active Unrestricted RN/SW License Required; NJ License Preferred
 

Knowledge:
•    Requires knowledge of the health care delivery system.
•    Requires knowledge of current Utilization Management, Case Management, and Prior Authorization strategies.
•    Requires knowledge of the nature and treatment of diseases and side effects of related therapy methods.
•    Requires knowledge of rehabilitation services that include physical, speech and occupational therapy.
•    Requires broad knowledge of Healthcare Maintenance Organizations.
•    Requires thorough knowledge of the HMO model and benefit contract.
•    Requires knowledge of PC's and window-based software applications.
•    Requires broad clinical 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:
•    Organizational and leadership skills
•    Oral and written communication skills
•    Analytical and problem solving skills
•    Decision making skills
•    Presentation skills
•    Analytical skills

•    Manage