Utilizes clinical expertise to interpret medical policy and medical criteria and coaches staff appropriately when making medical necessity decisions. Conducts clinically based discussions with nursing and medical staff (both internal staff and external customers). Leads teams by encouraging them to take ownership of their work processes and understand their role within the company. Helps teams to understand high-level business objectives and how their work is essential to the achievement of these objectives. Provides coaching and focuses on career development for team members. Manages performance of team members and delivers timely and appropriate performance feedback and training.
Major Job Functions/Components
• Manages day-to-day business area activities, provides leadership/direction to team members, and sets expectations. Acts as a technical resource for team members providing assistance/guidance on system issues, benefits, and work processes and procedures. Creates a positive work environment that fosters teamwork, empowerment, accountability, and ownership.
• Requests team input on work processes, quality improvements, goal setting, and decision-making. Takes ownership of and supports team decisions. Take action, guides and motivates others to support and reflect the core competencies.
• Identifies trends, determines root causes, and initiates appropriate action to resolve issues. Delegates to develop skills and knowledge of team members and increase business efficiency. Designs, develops, and implements tools and techniques for improvements and promotes change efforts of the organization within the team.
• Communicates company, business area, and team goals to employees. Collaborates with team members to draft Individual Plans of Work and team goals. Monitors individual performance and provides accurate and timely developmental feedback. Drafts team members’ performance evaluations, obtains appropriate sign-off, and reviews with team members. Works with team to develop team goals; coaches and supports team in achieving these goals. Ensures the establishment and implementation of performance goals and accountabilities. Measures and tracks team performance and provides constructive feedback to team members. Maintains accountability for achieving targeted results and communicates regularly with organization leadership regarding workloads, issues, projects, monitoring of team performance and staffing needs.
• Promotes cross-training among team members and ensures training needs are met. Provides one-to-one functional training of team members when necessary, to include assisting with the development of less experienced team leaders.
• Provides input and works with organization leadership in the development of budgets and goals and the management of compliance at the team level. Ensures goal alignment among teams. Updates goals as needed.
• Facilitates meetings and conducts formal presentations as needed. Conducts larger scale presentations or facilitates larger scale meetings for cross-functional or customer groups.
• Handles complex employee relation’s issues. Acts proactively and brings specific plans to management to recommend how to best address difficult issues. Encourages and reinforces effective team behavior. Assists in resolving conflicts between team members. Coaches team-building skills. Ensures a timely, consistent, and reliable flow of relevant information to employees. Ensures that team members understand and adhere to corporate policies.
• Performs special projects based on business area needs and other duties as assigned. Leads and represents the department on corporate projects that require independent, sound decision making and broad based understanding of effects on the department as a whole. Interacts with other units regularly through projects and accomplishes goals by working cross-functionally. Develops resource allocation strategies to meet changing business demands.
• Empowers employees to own customer concerns and take actions to provide superior customer service and solve problems, with regard to customer and business needs. Recommends and implements effective ways to monitor and evaluate customer concerns, issues, and satisfaction and to anticipate customer needs. Identifies and takes action regarding necessary process and procedural changes which will result in improved internal and external customer satisfaction.
• Assists with the recruitment and retention of staff.
• Acts as a medical resource for team members and other departments, providing assistance and guidance on medical necessity, bundling, pre-existing and pricing issues.
• Serves as liaison between Medical Review and the medical directors supporting the department.
• Works closely with Compliance to ensure that all functions including medical necessity reviews and determinations meet all requirements imposed by regulatory agencies such as NCDOI, NCQA, BCBSA, Federal, etc.
• Must possess a broad knowledge of and keep abreast of trends regarding CPT, HCPCS, ICD-9 coding, and HIPAA code sets such as NCCI.
• Must stay abreast of current clinical standards of care.
State Medical Review
• Analyzes timeliness reports to ensure ongoing compliance. Formulates corrective action plans to address areas of non-compliance.
• Performs activities that relate to Utilization Management delegated oversight including on-site visits to delegated entity.
• Manages consistency review process for all clinical staff. Results of the reviews are provided to individual staff for input into performance evaluations. Collaborates with manager to identify trends within the department and to plan additional training.
Senior Segment Programs - Case and Utilization Management
• Promotes and encourages staff to utilize essential elements of the nursing process in their job functions: assessment, planning, implementation, coordination, monitoring, and evaluation.
• Serves as a liaison between medical directors, key operational areas and staff as necessary to identify and resolve issues.
• Maintains current knowledge in areas of chronic care disease management, adult, and geriatric medicine.
• Responsible for the application, understanding, and compliance of Medicare regulations and standards (or other regulatory requirements) applicable to departmental operations.
• Demonstrates understanding of the Case Management process by consistently adhering to member privacy and confidentiality regulations, advocating for member safety and strict adherence to ethical, legal and accreditation/regulatory standards
• RN with valid NC license is required.
• 3 years previous full time direct clinical nursing experience or 3 years in the health insurance industry in utilization management, managing health conditions, understanding medical criteria, medical guidelines, medical policy, and NCQA and DOI, Medicare/CMS regulations.
• Demonstrated leadership skills (i.e. training, mentoring, coaching or assisting peers with issue resolution) or previous experience in a leadership role is required.
• Knowledge of Windows and Microsoft Office required.
• For Team Leads that supervise Case Managers: Certified Case Manager (CCM) certification is required within 2 years of obtaining the role of Team Lead. Team Leads in existence as of 4/1/10 will have two years to obtain certification.
Additional Critical Skills & Knowledge Needed for Job
• Experience in a health insurance environment preferred
• Knowledge of medical policy and healthcare claims administration is preferred.
• Keeps abreast of medical knowledge and care patterns, regulatory and governmental rules and regulations, and of BCBSNC policies related to care management.
• Takes ownership of personal development and continuous learning by networking with peers, joining relevant associations, staying abreast of current industry trends, etc.
• Medical management and sound decision making skills.
• Must possess the ability to build effective working relationships with providers, members, employers, and BCBSNC staff.
• Commitment to high quality customer service.
• Coaching skills and the ability to give, constructive feedback, and develop employees.
• Demonstrated ability to promote and support teamwork and team decision-making.
• Ability to build consensus and form partnerships with various levels of staff within and across an organization.
• Excellent negotiation, decision-making, and relationship-building skills.
• Excellent oral and written communication skills.
• Demonstrated analytical thinking skills.
• Ability to identify issues and recommend and implement solutions.
• Ability to make sound and independent business decisions in often high-pressure situations.