Provides the highest quality of effective, proactive and professional services to staff, members and providers in all aspects of Clinical Determinations, Case Management Services or Case Management of Appeals. Primarily responsible for oversight of all functions including: staffing, auditing, coaching, project management, staff development, quality management, as well as training and development.
- Manage the operational performance of one or more functions of the department to ensure performance standards are met and in compliance with state and federal regulations.
- Initiate operational and service initiatives to facilitate and promote quality, cost effective outcomes and minimize the fragmentation of health care delivery on the member.
- Manage the day to day planning and direction of all clinical and non-clinical staff, report on productivity and performance of staff.
- Collaborate in the management of programs to include evaluation, coordination, negotiation and documentation of department policies, procedures, and processes.
- Facilitate complex clinical and financial decision making by presenting thoroughly analyzed cases requiring high administrative approval or intervention.
- Oversee an integrated continuous quality improvement process to assure high quality care, customer satisfaction and contribution to financial performance.
- Provide guidance to staff in resolving problematic situations with beneficiaries, families, physicians and external entities.
- Manage investigations and respond to all client and provider complaints.
- Meet and collaborate with physicians regarding specific cases and troubleshoot on high profile and complicated cases.
- Assist the Director with budgets and has a good working knowledge of the budget and the budget tool.
- Provide leadership, coaching and mentoring to the department staff.
- Demonstrate support and leadership of the team to drive innovation and improve the coordination and quality of care.
- Collaboration with other areas of the organization to provide the support for quality and metrics geared towards quality programs and initiatives.
- Ensure processes, metrics and control environments are well defined and documented.
- Ensure effective and efficient execution of post service claims review
- Oversight of clinical professionals that interpret medical policy to review medical claims
- Identify medical expense savings through accurate medical reviews
- Partner with related departments to provide vendor review support
- Manage the review process for medical review department and ensures coding consistency in support of all lines of business.
- Communicate with and assist Medical Directors regarding coverage and other pertinent issues.
- Manage activities that relate to Utilization Management delegated oversight including on-site visits
- RN with valid NC license required.
- 5 years clinical experience in a health care environment.
- 3 years direct supervisory experience or leadership experience.
- Knowledge of Windows and Microsoft Office required.
- Comprehensive knowledge of laws, regulations and professional standards of care management practice in a managed care setting is strongly preferred.
- BSN preferred.
- Excellent negotiation skills.
- Excellent critical thinking and problem-solving skills.
- Effective verbal and written communications skills.
- Ability to develop and maintain collaborative relationships with internal and external customers.
- Proven ability to effectively communicate orally and in writing detailed and complex information at all levels that possess varying degrees of comprehension.
- Facilitation and presentation skills.
- Demonstrate analytical thinking skills. Ability to track and trend data, identify issues, recommend and implement solutions after a thorough risk assessment. Data driven decision making skills.
- Strong business and financial acumen
- Certified Professional Coder (CPC) preferred.