Summary
Responsible for the supervision and maintenance of the daily functions of the following areas: Utilization Review/Review Nurses, Case Management, Medical Review, Health/Disease Management, Quality Management, and/or Appeals, to include departmental staff and specialty programs. Responsible for all data collection for specialty programs and ensures appropriate levels of healthcare services are provided.
Description
•35% Supervises day-to-day activities for assigned staff. Identifies training needs of staff. Verifies accuracy, efficiency, and effectiveness of workflow functions. Develops and oversees the implementation and administration of specialty programs (wellness, preventive, and/or employer worksite programs).
•35% Supervises staff to include approval of time, leave, performance reviews, etc. Selects/trains/motivates staff in providing excellent customer service with customers, marketing, management/others.
•15% Develops/maintains/updates procedures/documentation for conducting audits. Develops/communicates department standards and expectations of staff. Performs quality control functions for work performed. Develops work plans to improve quality performance.
•10% Conducts analysis of program component. Collects data for outcomes reporting. Prepares/reviews/maintains weekly/monthly reports for management. Oversees all data collection and URAC/NCQA compliance activities for related programs.
•5% Coordinates with other corporate departments to ensure effective communication.
• 35% Supervises day-to-day activities for assigned staff. Identifies training needs of staff. Verifies the accuracy, efficiency, and effectiveness of workflow functions. Develops and oversees the implementation and administration of specialty programs (wellness, preventive, and/or employer worksite programs).
• 35% Supervises staff to include approval of time, leave, performance reviews, etc.Selects/trains/motivatestaff in providing excellent customer service with customers, marketing, management/others.
• 15%Develops/maintains/updatesprocedures/documentationfor conducting audits.Develops/communicatesdepartment standards and expectations of the staff. Performs quality control functions for work performed. Develops work plans to improve quality performance.
• 10% Conducts analysis of program component. Collects data for outcomes reporting.Prepares/reviews/maintainsweekly/monthly reports for management. Oversees all data collection and URAC/NCQA compliance activities for related programs.
• 5% Coordinates with other corporate departments to ensure effective communication.
Required Education:
Bachelor's degree in Nursing OR
Graduate of Accredited School of Nursing
Required Work Experience:
Five years of clinical experience.
One year of experience in a team lead/leadership role or equivalent military experience in grade E4 or above (may be concurrent).
Required Skills and Abilities:
Understanding of insurance and benefit programs as it relates to health management coverage.
Working knowledge of managed care and/or various forms of health care delivery systems.
Knowledge of specific criteria/protocol sets and the use of the same.
Knowledge/understandingof the quality improvement process.
Ability to work independently, prioritize effectively, and make sound decisions.
Excellent communication skills. Ability to work with a wide variety of internal and external customers.
Good judgment skills. Demonstrated customer service, organizational, and presentation skills.
Demonstrated verbal and written communication skills.
Analytical, critical thinking, and math skills necessary to collect, analyze, and report data.
Ability to persuade, negotiate, or influence others.
Ability to handle confidential or sensitive information with discretion. Ability to direct, motivate, and assess the performance of others.
Required Software and Tools:
Microsoft Office.
Required License:
Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.
Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities.
If you need special assistance or an accommodation while seeking employment, please e-********** or call 1-800-288-2227, ext. 43172 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
