Job Summary:

Responsibilities:

• Manages, analyzes and coordinates the daily activities of the unit to ensure departmental productive goals are met with regards to quality timeliness, accuracy and consistency of medical decisions.
• Ensures staff meets all regulatory requirements and comprehends and complies with best practices, professional standards, internal policies and procedures.
• Conducts continuous evaluation of workflows and seeks to improve processes that impact the department.
• Coordinates data collection, reviews compliance reporting and identifies opportunities for improvements. Identifies and implements cost saving/revenue generating opportunities.
• Serves as key liaison between Medical Directors, Management leadership, and staff. Also serves as a medical resource to members and providers, as well as non-clinical staff.
• Develops key performance indicators to evaluate level of service for internal and external customers.
• Acts as a subject matter expert for difficult and complex matters. Represents the Plan with external customers, providers and agencies. Represents the department on internal committees and participates in special projects.
• Assists Manager in coordinating regulatory, quality and accreditation activities. Performs other duties as assigned by management.
• Creates and champions an atmosphere within the team, which fosters open communication, teamwork, ownership, and a collaborative cross-departmental environment to implement, optimize and share continuous improvement processes.
• 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.
• Assists in preparing and monitoring the budget to ensure administrative cost objectives are met.

The information above is intended to describe the general nature of the work being performed by each incumbent assigned to this position. This job description is not designed to be an exhaustive list of all responsibilities, duties, and skills required of each incumbent.

Addendum:

For Behavioral Health Clinical Operations Only

• Required to work one holiday shift per year

Education:

• Requires a Nursing degree or a Masters in a Behavioral Health related field or a Bachelors in a health related field.

Experience:

• Requires a minimum of two years' full time acute healthcare/direct clinical care experience to the consumer.
• Requires a minimum of one year direct supervisory experience or demonstrated supervisory experience leading teams in a matrix management environment.
• Requires minimum of 12 months experience in a managed care setting or the health insurance industry
• Prefer a minimum of three years' experience as a case manager.

Additional licensing, certifications, registrations:

• Active Unrestricted NJ LCSW, LMFT, LPC, or RN/PT License Required
• Medicaid Case Management Only: Active Unrestricted NJ LSW, LCSW, LMFT, LPC, or RN/PT License Required
• Prefer certification as a Case Manager

Knowledge:

• Requires knowledge of Utilization Management (UM) and managed care principles.
• Requires knowledge of the Case Management/Disease Management Standards of Practice.
• Requires knowledge of health care systems and medical documentation.
• Requires knowledge of State Mandates and Regulations.
• Requires knowledge of regulatory bodies and their processes.
• Requires knowledge of NCQA accreditation standards.
• Requires knowledge of community health resources.

Skills and Abilities:

• Requires the ability to express thought clearly and concisely both orally and written.
• Requires the ability to obtain the skills possessed by the team members and system technical competence.
• Requires the ability to effectively lead team members in diversified tasks
• Requires excellent organizational skills.
• Requires excellent presentation skills.
• Requires the ability to think analytically and to report findings in an 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 % (If Applicable):

• Travel required to other Horizon offices, provider locations and/or for oversight of remotely located workforce members in accordance with Company needs

Salary Range:

This position is eligible for sales incentive compensation in addition to base pay. 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

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.