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Manager, Clinical Teams – Behavioral Health Utilization Management, Multistate

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RQ0018384 Job Description     We’re hiring a Manager, Clinical Teams for the Behavioral Health Utilization Management Team! In this critical role, you will collaborate and engage with multiple internal stakeholders and external customers (i.e. providers, vendors, employer groups) to implement population health management and promote a collaborative, integrated culture across lines of business/segments. Supports value-based strategy by leading multiple clinical or non-clinical teams/staff focused on improving member health through proactive and professional services in the following areas: clinical determinations, case management, disease management, wellness, medical policy, medical review, and/or related services.    What You’ll Do

  • Assist in the development of operational strategies and innovative solutions for area(s) of clinical oversight; facilitate favorable medical expense, administrative pricing and/or efficiencies.
  • Maintain awareness of trends, developments, and governmental regulations in managed health care organizations and product line(s) under leadership purview and recommends associated policy positions, new initiatives and/or existing program changes to improve the company’s competitive position.
  • Use competitive intelligence to guide, consult and drive strategic program and product development and management
  • Manage the operational performance of multiple integrated clinical functions across multiple lines of business, including Commercial, Medicare and FEP.   Manage Clinical Determinations, Wellness, Medical Policy, Medical Review and/or related services for different line(s) of business to ensure performance standards are met and in compliance with employer groups, FEP Directors’ Office, and/or applicable state and federal regulations.
  • Initiate and manage service initiatives/programs to facilitate and promote quality, cost effective outcomes and minimize the impact of fragmented health care delivery on the customers.
  • Collaborate and integrate with internal and external customers to deliver a fully integrated care delivery model and seamless member experience and to investigations or escalated/high profile cases; troubleshoot and provide guidance to staff to ensure resolutions and improved customer experience.
  • Facilitate and incorporate complex clinical and financial decision making in the day to day operations by presenting thoroughly analyzed cases requiring high administrative approval or intervention.
  • Establish and monitor performance and production metrics and goals, including process measures, outcomes measures and financial measures.
  • Manage, and/or support implementation of departmental, divisional, or corporate projects that impact the clinical aspects of the service(s) under leadership purview.
  • Assist with the evaluation and management of vendor and partnership opportunities.
  • Collaborate with the leadership accountable for applicable vendors supporting business area needs.
  • Oversee or participate in internal committees relevant to work responsibilities; may represent the department through presentations and/or active participation in cross functional organizational committees
  • Implement an integrated continuous quality improvement and change process to assure high quality care, innovation, customer satisfaction and contribution to financial performance of the Program or Operations.
  • Responsible for the oversight, compliance, and execution of all regulatory or accreditation activities and processes including the accuracy and compliance of the State, Federal, and other accrediting bodies (i.e. ERISA, DOI, NCQA, CMS).
  • Serve as primary contact for compliance and regulatory body audits related to the services under leadership purview.
  • Ensure programs and operational changes are communicated to all appropriate internal and external stakeholders in accordance with policies and regulations.
  What You Bring
  • Bachelor’s degree and 8+ years of relevant experience.
  • RN, FNP or other APN certification.  For Behavioral Health specific roles, other applicable licensure will be considered (PhD, LMSW, LCSW, LPC, LMFT, etc).
  • Must have valid NC license or multistate compact license.
  • 3+ years of direct supervisory or leadership experience.
  • Experience in behavioral health focused population health, care management, clinical review or coding, or utilization management in a health care organization/system or health insurance
  Bonus Points (preferred qualifications)
  • Demonstrated experience managing Behavioral Health Utilization Management Teams
  What You’ll Get
  • The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community
  • Work-life balance, flexibility, and the autonomy to do great work
  • Medical, dental, and vision coverage along with numerous health and wellness programs
  • Parental leave and support plus adoption and surrogacy assistance
  • Career development programs and tuition reimbursement for continued education
  • 401k match
  #LI-Hybrid             Salary Range At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets,  licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.   *Based on annual corporate goal achievement and individual performance. $107,901.00 - $172,642.00    Skills Care Management, Clinical Experience, Clinical Quality Management, Clinical Review, Code of Federal Regulations, Health Insurance Operations, Managed Care, Patient Safety, People Management, Policy Compliance, Policy Implementation, Population Health Management, Quality Improvement, Quality Management, Regulatory Compliance, Standards Compliance_____________________________________________________________________ JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Blue Cross and Blue Shield of North Carolina in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All our career opportunities are published on https://bcbsnc.wd5.myworkdayjobs.com/en-US/BCBSNC. If you have already provided your personal information that you suspect is fraudulent activity, please report it to your local authorities. Any fraudulent activity should be reported to: HR.Staffing@BCBSNC.com.
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