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

Job Summary:

Responsible for providing clinical direction and leadership for the integrated clinical operations teams, which include pre-certification, pre-determination, concurrent review, complex case management, and chronic care management. Working in collaboration with the Sr. Medical Director for Medical Management, leads staff in developing, translating and executing Health Affairs and Medical Management strategies and operational objectives with primary responsibility for achieving cost of care goals, quality outcomes, customer satisfaction, ACR goals, and meeting accreditation and regulatory requirements.

Responsibilities:

Directs department by providing strategy and related goals to day-to-day managers, ensuring appropriate staffing, overall client satisfaction and appropriate and effective level of service delivery.

Assures Clinical Operations is effectively integrated to support the implementation and operational effectiveness of the Community Based Care Management operational model.

Develops annual Medical Management work plan, Annual Medical Management Program Description, Annual Medical Management Program Evaluation, and additional reports as required for meeting accreditation and regulatory requirements.

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 and accreditation requirements and comprehends and complies with best practices, professional standards, internal policies, and procedures.

Determines departmental budget and conducts ongoing expense management.

Develops/implements policies and manages clinical services operations to achieve financial efficiencies and clinical effectiveness.

Identifies operational processes, determines areas for improvement and sets measurement in place to enhance operations, reduce operating cost, standardize best practices and ensure appropriate compliance with quality standards.

Conducts or directs assessments of clinical services provided to Horizon BCBSNJ members. Identifies and implements strategic initiatives to ensure significant clinical improvements while reducing administrative costs.

Formulates guidelines around caseload and discharge practices to meet objectives of quality, cost containment and member satisfaction.

Establishes and achieves ROI targets.

Provides direction for developing and ensuring implementation of ongoing training programs and procedures to monitor, evaluate and improve overall quality of clinical services and increase customer satisfaction.

Provides leadership to multiple levels of professional staff while serving as a role model, teacher and coach to clinical professionals.

Forms strategic operational relationships, particularly with hospitals, health systems, PCMHs, ACOs, and community resources which will support clinical services programs growth and expansion, development of new programs and achievement of program targets.

Facilitates the establishment of effective and efficient internal and external customer interfaces.

Works cross functionally and collaboratively with various division/department leaderships to develop strategic initiatives as ongoing improvements.

Education/Experience:

Bachelors degree in Science or Business required. Masters degree preferred.

Diversified health care background with 5-10 years experience in managed care.

Minimum of 5 years Director level/leadership experience.

Demonstrated operations management experience and results orientation.

Thorough understanding of managed care principles, models and financing.

Knowledge of UM, DM, CM and Prior - Authorization.

High energy with solid clinical experience, in-depth knowledge of the managed care industry.

Additional licensing, certifications, registrations:

Valid and unrestricted NJ RN, LCSW, LPC, or LMFT license required.

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:

Strong leadership, execution and customer (internal/external) satisfaction skills.

Strong analytical skills to evaluate data from various sources, identify trends and issues and develop recommendations to senior management.

Innovative problem solving skills and ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action.

Proficiency in analyzing and interpreting financial trends.

Strong relationship building ability to work collaboratively across departments/divisions.

Experience leading and motivating clinical professionals.

Exceptional interpersonal and presentation skills.

Knowledge of state, federal and industry regulatory and compliance requirements.

High level of credibility and integrity.

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.

Salary Range:

$150,300 - $205,065

​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity.  This range has been created in good faith based on information known to Horizon at the time of posting.  Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

Comprehensive health benefits (Medical/Dental/Vision)

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.  Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.