Supv, Clinical Appeals

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 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.

1. 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.

2. Ensures staff meets all regulatory requirements and comprehends and complies with best practices, professional standards, internal policies and procedures.

3. Conducts continuous evaluation of workflows and seeks to improve processes that impact the department.
4. Coordinates data collection, reviews compliance reporting and identifies opportunities for improvements. Identifies and implements cost saving/revenue generating opportunities.

5. 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.
6. Develops key performance indicators to evaluate level of service for internal and external customers.
7. 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.

8. Assists Manager in coordinating regulatory, quality and accreditation activities. Performs other duties as assigned by management.
9. 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.
10. Manages, directs, and develops staff by providing feedback and coaching. Administers performance and salary reviews for staff. Ensures staff meets all regulatory requirements and comprehends and complies with best practice methodology, professional standards, and internal policies and procedures. Assists in preparing and monitoring the budget to ensure administrative cost objectives are met.
The information above is intended to describe the general nature of the work being performed by each incumbent assigned to this position. This job description is not designed to be an exhaustive list of all responsibilities, duties, and skills required of each incumbent.

Addendum

For Behavioral Health Clinical Operations Only

-Required to work one holiday shift per year

Functional Competencies Building a Successful Team; Information Monitoring; Planning & Organizing; Work Standards; Stress Tolerance; Decision Making; Facilitating Change; Managing Conflict; Building Trust.

Education/Experience:
-Requires a Nursing degree or a Masters in a Behavioral health related field or a Bachelors in a health related field.

1. Requires a minimum of two years' full time acute healthcare/direct clinical care experience to the consumer.

2.Requires a minimum of one year direct supervisory experience or demonstrated supervisory experience leading teams in a matrix

management environment.

3.Prefer certification as a case manager.

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

5.Requires minimum of 12 months experience in a managed care setting or the health insurance industry.

Additional licensing, certifications, registrations:
-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


Knowledge:

-Requires knowledge of Utilizati