Manager - Pre Service Medical Review

Administer the clinical and non-clinical referral authorization and voluntary pre-service review within the Pre-Service Medical Review for all lines of business in order to improve provider satisfaction, medical cost management, and administrative performance by: Resolving clinical and non-clinical inquiries in a manner intended to enhance member and provider experience. Ensuring compliance within the Pre-Service Medical Review to regulatory and legislative mandates and operational objectives through standardized clinical and non-clinical processes. Coaching the Pre-Service Medical Review members toward becoming a high performing team. Identifying, implementing, and monitoring continuous quality improvement initiatives (CQI).

What You Will Be Doing

• Manage the clinical and non-clinical capabilities using all BCBSF management processes. 
• Monitor clinical and non-clinical operational performance i.e., Centre-Vue, Siebel, Quest, etc.) within the Pre-Service Medical Review to ensure alignment with budgeting, staffing, and performance objectives (i.e., budgeting, resource management, etc.) 
• Lead Pre-Service Medical Review members to meet individual and team and operational goals and objectives (e.g., telephone, fax, held authorizations, inventories, etc.) to achieve the desired cultural attributes, and build an effective team; provide guidance and clarification of clinical and non-clinical standards to clinical and non-clinical staff, and effectively manage among the regional department. 
• Coach Pre-Service Medical Review members to coordinate and resolve issues; assist and facilitate career/succession planning with Pre-Service Medi la Review members. 
• Ensure adherence to regulator agencies such as NCQA, HCFA, DOI, and AHCA; ensure adherence to policy and procedure within the Pre-Service Medical
• Review, and facilitate and enable boundary management within and outside of the Pre-Service Medical Review including monitoring existing service level agreements and identifying the need for new agreements. 
• Lead team to identify, implement, and monitor continuous quality improvement initiatives (CQI) for standardized clinical and non-clinical processes.

What We Require

• 5+ years related work experience in managed care
• 2+ years direct supervisory/management experience 
• Related Bachelor’s degree or additional related equivalent work experience 
• Occasional travel required. (10% travel within the State of Florida) 
• Leadership skills (communicating, inspiring, empowering, resolving conflicts, etc.) 
• Knowledge of general management practices (organizing, planning, controlling, budget/expenditure control, HR program/practices) in a participative environment. 
• Excellent written and verbal communication skills with the ability to communicate effectively with all levels of an organization and diverse audiences. 
• Proven ability to build relationships within the business area, across the organization, and external to BCBSF. 
• Proven ability to resolve issues and barriers. 
• Continuous improvement (CI) processes (Six Sigma or other TQM methodologies and tools). 
• Knowledge of and ability to coach on the following various service tools, processes, and programs including: Health care regulatory requirements. 
  excellence in customer service, knowledge of Microsoft Office including Outlook.

What We Prefer

• RN - Registered Nurse - State Licensure And/Or Compact State Licensure Active Florida RN license 

• Advance degree in related field. Knowledge of CMCA, CCMS, Siebel 
   

General Physical Demands

• Exerting up to 10 pounds of force occasionally to move objects. 

• Jobs are sedentary if traversing activities are required only occasionally. 

What We Offer
As a Florida Blue employee, you will be at the heart of GuideWell’s vision – to lead the nation in transforming health through compassionate, connected, and technology-enabled care that delivers personalized value and empowered living. 

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to: 
 

• Medical, dental, vision, life and global travel health insurance
• Income protection benefits: life insurance, short- and long-term disability programs
• Leave programs to support personal circumstances
• Retirement Savings Plan including employer match
• Paid time off, volunteer time off, 10 holidays and 2 well-being days
• Additional voluntary benefits available; and a comprehensive wellness program

Employee benefits are designed to align with federal and state employment