This position has oversight of the BlueCross BlueShield enterprise for clinical operations, utilization management, and population health. This individual will oversee the development of clinical strategies and operational solutions for the organization, including the development of clinical programs, standards and policies designed to ensure cost effective, quality health care outcomes for members. This will include implementation of changes and reorganization resulting from third party objective evaluation of current processes and structure. This position will work with clinical and nonclinical staff in the areas of utilization management, care coordination, case management, disease management, population health, behavioral health, and wellness. Incumbent must work closely and collaboratively across the enterprise for proficient systems reporting and training. Additionally, the incumbent would be expected to collaborate with product development, sales, and account management. This position must lead several direct reports at the manager level and lead enterprise wide projects demonstrating solid knowledge and business rules associated with all lines of business.
In addition, this position supports the competitive positioning of care programs in the market place via effective care management. Analyzes andreports significantutilization trends, patterns, and impact to appropriate departmental and medical staff committees. This position will beresponsible for ensuring compliance with applicable accreditation standards, government regulations, and all applicable businesscontracts. This position will fully support continuous quality improvement and effectiveness of operations as well as the development and management of operations staff. This position directs program development and modification to meet member needs by using emerging tools and metrics.
Job Duties & Responsibilities
- Leads, manages and develops a best-in-class, high performing, high morale health services organization with an emphasis on nimbleness and flexibility in a rapidly evolving marketplace
- Communicate on an ongoing basis and in an optimal manner the departmental goals
- Serve as enterprise-wide subject matter expert on health services delivery
- Function as a team leader or facilitator with cross-functional teams to gain consensus and coordinate development and process improvement efforts
- Ensure that all programs and processes meet requirements of URAC, applicable contracts, NCQA where applicable, and FEP requirements
- Direct managers of UM, CM, Care Coordination and Wellness. Integrate with medical directors performing utilization management and care management consultations for BCBST to ensure consistent and timely reviews and appeals
- Coordinate with the BCBST Medical Policy Department to ensure appropriate connection between medical policy and utilization management/case, management/care coordination criteria, and decisions. Coordinates with vendor programs and adds supplemental programs where needed to meet member needs
- Identify, communicates, and leads implementation of measurable continuous improvements that assist BCBST maintain a strong competitive position in the rapidly changing healthcare market.
- Provides leadership for the development of new initiatives that positively affect medical cost trend leading to improved corporate financial results
- Works directly with customers and providers in reviewing RFP’s, providing consultation on programs for clinical areas of concern, and working through issues with workflow and information sharing to provide clinical services
- Provides leadership for enterprise-wide projects that affect clinical staff such as major system initiatives
- Bachelor Science in Nursing, or relevant Healthcare field or equivalent work experiencerequired
- Registered Nurse with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.
- MBA, MPH, MSN highly preferred
- Minimum 10 years of demonstrated progressive and successful healthcareexperience with 6+ years of managed care health services/clinical operationsexperiencerequired
- Minimum 5 years of management experiencerequired
- Current knowledge and recent track record of driving superior, measurable health care delivery results in a managed care organization
- Exceptional organizational and management skills and the ability to meet established targets and deadlines
- Outstanding leadership skills; demonstrated track records of creating high-performance work environments and developing future leaders
- A demonstrated ability to lead utilizing LeanSix Sigma or similar methodologies to identify opportunities, conduct analyses, and develop and implement the improvements
- Prior clinical experience is preferred
- Strong analytical skills and a high degree of comfort with data driven pathways and outcomes
- Excellent communication, teaming and interpersonal skills, and the ability to initiate and maintain cross-team relationships
- Case Management certification preferred
- Process improvement training/certification such as LeanSix Sigma
Job Specific Requirements:
Registered Nurse with BSN highly preferred.
Managed care experience with Utilization Management and Care Management highly preferred.
Grade 15, BBOF, CAP Incentive Program