Mgr, RN Clinical Ops at Horizon Blue Cross Blue Shield of New Jersey

Hopewell, New Jersey, United States -

Full Time

Start Date

Immediate

Expiry Date

18 Jan, 26

Salary

147420.0

Posted On

20 Oct, 25

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Leadership, Communication, Analytical Skills, Problem Solving, Quality Assurance, Risk Management, Regulatory Compliance, Budget Management, Staff Development, Policy Implementation, Team Management, Clinical Operations, Healthcare Knowledge, Decision Making, Presentation Skills, Organizational Skills

Industry

Insurance

Description

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. This position is responsible for providing leadership and oversight of the overall clinical and non-clinical operations. Assists Director in establishing, interpreting and implementing new and existing company policies and procedures. The manager is also responsible for the adherence and maintenance of the regulatory agency requirements for DOBI, NCQA, DOL, DMHAS and CMS for analyzing utilization, performance trends, and quality of health care to ensure timely and cost effective delivery ASO (Administrative Services Only) managed care accounts are a type of self-funded health plan where an employer, known as the "plan sponsor," hires a third-party administrator (TPA) or an insurance company to handle the administrative tasks of benefits and claims processing, but the employer remains responsible for paying the actual employee claims. Responsibilities: Manages, analyzes and coordinates the daily activities of the unit to ensure departmental goals are met with regards to timeliness, accuracy and consistency of medical decisions. Manages and directs staff to ensure overall client satisfaction, appropriate level of service delivery, quality outcomes. Recognizes and identifies opportunities to improve the quality of Care/services and initiates steps and activities to advance outcomes. Subject matter expert for multiple blue list projects, mandate office projects, task forces/Regulatory Committees. Develops and implements policies, procedures, and ad hoc reports to meet regulatory guidelines. Maintains and monitors the departmental budget to ensure administrative costs are managed. Subject matter lead for IPRO, CMS, Burchfield, NCQA audits. Identifies and implements business process improvements to identify efficiencies and cost savings opportunities. Interfaces with other teams and plan areas to assure consistent application of policies and procedures and to facilitate inter-unit/department projects. Represents the Plan with CBU with external group customers and Regulatory affairs for external agencies. Represents the unit on corporate issues and/or in the event of Director's absence. Creates and champions an atmosphere within the team, which fosters open communication, increase employee engagement, teamwork, ownership, and a collaborative cross-departmental environment to implement, optimize and share continuous improvement processes. Determines departmental budget and conducts ongoing expense management. Manages, directs, and develops staff by providing feedback and coaching. Administers performance and salary reviews for staff. Ensures staff meets all regulatory requirements and comprehends and complies with best practice methodology, professional standards, and internal policies and procedures. Disclaimer: 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. Education/Experience: High School Diploma/GED required. Bachelor degree in Nursing or health related field preferred or relevant experience in lieu of degree. Requires minimum of five (5) years’ experience in a healthcare-related field. Requires minimum of five (5) years broad clinical experience. Requires minimum of three (3) years direct supervisory experience or demonstrated supervisory experience leading teams in a matrix management environment. Prefers professional certification in a clinical specialty as appropriate to the business unit. Additional licensing, certifications, registrations: Active Unrestricted NJ LCSW, LSW, LMFT, LPC, or RN License required. Knowledge: Requires strong knowledge of functional tasks performed within department. Requires knowledge in the principles of risk management and quality assurance. Requires knowledge of NCQA standards. Requires knowledge of State Mandates and Regulations. Requires knowledge of regulatory bodies and their processes. Prefer knowledge of Plan products, applications, policies, procedures and systems. Skills and Abilities: Requires excellent organizational skills and ability to set priorities. Requires excellent oral and written communication skills. Requires excellent presentation skills. Requires comprehensive leadership and decision-making skills. Requires strong analytical, problem solving, and critical analysis skills to report findings in a complete, succinct and accurate manner. 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 Outlook; should be knowledgeable in the use of intranet and internet applications. Travel : Travel required to other Horizon offices, provider locations and/or for oversight of remotely located workforce members in accordance with Company needs. Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware Salary Range: $108,000 - $147,420 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 Disclaimer: 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. 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. About Us We are the leading health insurer in New Jersey, trusted by generations of families and businesses. We are dedicated to enriching the lives and health of our members and the New Jersey communities we serve, because we live and work here too. Our Mission We empower our members to achieve their best health. Our Vision We are New Jersey’s health solutions leader driving innovations that improve health care quality, affordability and member experience in the markets we serve.

Responsibilities

The manager is responsible for providing leadership and oversight of clinical and non-clinical operations, ensuring adherence to regulatory agency requirements. They manage daily activities to meet departmental goals and improve the quality of care and services.