MLTSS Supervisor RN/SW

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health.  For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. 

The position is responsible for leading the managed long term support and services program clinical care team in a hands-on manner to provide exceptional service to the customer and contain medial 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 corporate policies and procedures and are compliant with contractual, state and federal guidelines. Serves as a medical resource to members and providers, and non-clinical staff.

Responsibilities:

• Supervises, 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.
• Continuously evaluates workflow issues and seek to improve processes that impact the managed long term support and services department.
• Coordinates data collection, reviews compliance reports and identifies opportunities for service improvements.
• Recommends, develops and implements department polices and procedures and interfaces with other areas to insure consistent applications.
• Liaison between Medical Directors and staff.
• 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 requirements and comprehends and complies with best practices, professional standards, internal policies, and procedures.
• Performs the operational duties of a specific clinical care team.
• Ensures an atmosphere within the team, which fosters open communication, teamwork, ownership, and empowerment to make decision.
• Develops key performance indicators to evaluate level of service for internal and external customers.
• Acts as technical expert and reference point for difficult and complex matters.
• Facilitates the creation of service and processing innovations within the team. Shares innovations with other teams and market divisions.
• Assists in preparing and monitoring the budget to ensure administrative cost objectives are met. Identifies and implements cost saving/revenue generating opportunities.
• Interprets and executes policies for the team.
• Participates in special projects initiated by the Plan.
• Assists Manager in coordinating regulatory, quality and accreditation activities.
• Represents the Plan with external customers, providers and agencies.
• Represents the department on internal committees

Education/Experience:

• High School Diploma/GED required
• Bachelor degree preferred or relevant experience in lieu of degree
• Requires two (2) - four (4) years acute healthcare experience.
• Prefers one (1) year experience as a supervisor.
• Prefers one (1)- three (3) years experience in the health insurance industry.
• Certification as a case manager preferred.
• Professional certification in a clinical specialty and at least three years experience as a case manager preferred.

Additional licensing, certifications, registrations:

• Active Unrestricted NJ RN/SW License Preferred. Candidates with a restricted license will not be considered.

Knowledge:

• Requires knowledge of Utilization Management (UM) and managed care principles as they relate to the CCM process and Elderly Frail /Managed Medicaid Population based CM
• Requires knowledge of the Case Management/Disease Management Standards of Practice.
• Requires knowledge of health care systems and medical documentation.
• Requires understanding of claims processing, contracting and enrollment.
• Requires knowledge of State Mandates and Regulations, including HIPAA and HCQA.
• Requires knowledge of regulatory bodies and their processes including HCFA and DOBI.
• Requires knowledge of NCQA and URAC accreditation criteria related speci