Under the direction of the Vice President of Health and Medical Management (HMM), the FEP Director is responsible for the overall clinical operations of the FEP program serving over 100 K members. This includes ensuring that both the case management and utilization management services required as part of the FEP program are delivered in a high quality manner and that they meet all the regulatory and compliance requirements of the FEP program. Works in coordination with Quality and Compliance Lead to ensure all clinical goals of the Clinical Quality Incentive Program (CQIP) program are met and BCBSMA receives the maximum payout possible associated with the CQIP. The overall clinical program outcomes support and meet expectations of the overarching FEP Plan Incentive Program (PIP).
This is a high profile clinical leadership role that requires close collaborationwith the BCBSMA SeniorDirector of FEP Business Operations as well asother divisionswithin BCBSMA and ensure alignmentwith BCBSMA strategic direction and business practices. The clinicalDirector willwork closelywith the nationalDirector’s Office (DO) and the DO’s designated clinical account manager for the BCBSMA plan. In this role serves as the lead for requests from the DO related to clinical information andreporting. Represents BCBSMA at national FEP conferences and on national committees, often presenting to and consultingwithother FEP Blues plans around best practices.
- Provide senior clinical leadership and management to the case management, including chronic condition management and utilization management teams, including oversight of measurement and outcomes,
- Works in close collaboration with the quality and compliance leadership and team.
- Works in partnershipwith BCBS Finance Director to develop the annual budget, document and substantiate all budget expenditures and ensures compliance with government budget regulations.
- Assist in the development, training and implementation of clinical and administrative policies and procedures in support of internal BCBSMA, FEP DO (national) and external regulatory requirements
- Implement and manage measurement tools to identify continuous process improvement; including Cost Benefit Analysis CBA tools
- Develop, implement and evaluate the teams’ quality management goals and attainment of objectives
- Participate in inter-departmental committees/teams to develop proactive management solutions and implement proactive case management and chronic condition management programs
- Strive to meet or exceed savings goals for case management
- Lead the development of case management and chronic condition management workflows
- On an annual basis, develops individual performance plans for clinical managers and provides ongoing review for all team members
- Ensures all staff participate in performance coaching programs; helps develop and evaluate these program on an ongoing basis
- Facilitate communication and trainings with FEP Director’s Office re: CM/CCM/UM Programs and resource
- Participates in NQCA accreditation with expectation of achieving status of excellent
- Jointly develop clinical strategies to improve CM/CCM/UM efficiency and effectiveness of care coordination and utilization management reviews withassociate, peers and leaders
- Create and promote an environment of change and learning
- Participate in cross –functional teams to facilitate with implementation of department goals and objectives to ensure the achievement of corporate standards and goals
- Otherresponsibilitiesas assigned by leadership.
Qualifications (Knowledge, skills and abilities):
- Experiencewith data analysis, outcome measurements and results interpretation
- Must be knowledgeable of care management, disease management and concepts around behavior change
- Experience in benchmarking organizations; familiarity with ‘best in class’ and emerging care management practices and potential application to existing environment
- Problem-solver who thrives and is able to adapt in fast-paced environment
- Demonstrated leadership skills
- Ability to listen and to respect others’ opinions
- Ability to acknowledge and supportdiversity in the workplace
- Requires initiative and highly developed verbal and written communication, interpersonal, planning and analytical skills and ability to develop and integrate projects into operations
- Licensed Clinician (RN, NP, PA, LICSW) with5-7years health care management in managed care setting
- 5-7years in leadership role in health care management
- Excellent computer skills required
- Strong Project management skills
- Bachelor’s Degreerequired, Masters Degreepreferred