Mgr, RN Clinical Ops

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

Job Summary:

This position is responsible for providing leadership and oversight of the overall clinical and non-clinical operations. Assists Director in establishing, interpreting and implementing new and existing company policies and procedures. The manager is also responsible for the adherence and maintenance of the regulatory agency requirements for DOBI, NCQA, DOL, DMHAS and CMS for analyzing utilization, performance trends, and quality of health care to ensure timely and cost effective delivery

Responsibilities:

• Manages, analyzes and coordinates the daily activities of the unit to ensure departmental goals are met with regards to timeliness, accuracy and consistency of medical decisions.

• Manages and directs staff to ensure overall client satisfaction, appropriate level of service delivery, quality outcomes.

• Recognizes and identifies opportunities to improve the quality of

• Care/services and initiates steps and activities to advance outcomes.

• Subject matter expert for multiple blue list projects, mandate office projects, task forces/Regulatory Committees.

• Develops and implements policies, procedures, and ad hoc reports to meet regulatory guidelines.

• Maintains and monitors the departmental budget to ensure administrative costs are managed.

• Subject matter lead for IPRO, CMS, Burchfield, NCQA audits.

• Identifies and implements business process improvements to identify efficiencies and cost savings opportunities.

• Interfaces with other teams and plan areas to assure consistent application of policies and procedures and to facilitate inter-unit/department projects.

• Represents the Plan with CBU with  external group customers and Regulatory affairs for external agencies.

• Represents the unit on corporate issues and/or in the event of Director's absence.

• Creates and champions an atmosphere within the team, which fosters open communication, increase employee engagement, teamwork, ownership, and a collaborative cross-departmental environment to implement, optimize and share continuous improvement processes.

• Determines departmental budget and conducts ongoing expense management.

• 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.

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 degree in Nursing or health related field preferred or relevant experience in lieu of degree.

• Requires minimum of five (5) years’ experience in a healthcare-related field.

• Requires minimum of five (5) years broad clinical experience.

• Requires minimum of three (3) years direct supervisory experience or demonstrated supervisory experience leading teams in a matrix management environment.

• Prefers professional certification in a clinical specialty as appropriate to the business unit.

Additional licensing, certifications, registrations:

• Active Unrestricted NJ LCSW, LSW, LMFT, LPC, or RN License required.

Knowledge:

• Requires strong knowledge of functional tasks performed within department.

• Requires knowledge in the principles of risk management and quality assurance.

• Requires knowledge of NCQA standards.

• Requires knowledge of State Mandates and Regulations. Requires knowledge of regulatory bodies and their processes.

• Prefer knowledge of Plan products, applications, policies, procedures and systems.

Skills and Abilities:

• Requires excellent organizational skills and ability to set priorities.

• Requires excellent oral and written communication skills.

• Requires excellent presentation skills.

• Requires comprehensive leadership and decision-making skills.

• Requires strong analytical, problem solving, and critical analysis skills to report findings in a