Manager Payment Integrity Clinical - Eagan, United States - BlueCross BlueShield of Minnesota

Description

About Blue Cross

Blue Cross and Blue Shield of Minnesota is one of the most recognized and trusted health care brands in the world with 2.5 million members. We're committed to reinventing health care to improve health for our members and the community. We hope you'll join us.

How Is This Role Important to Our Work?

This role is responsible for leading the day to day operational performance of a care management team while ensuring high quality care management and adherence to regulatory and compliance standards for commercial and/or government program lines of business. The manager is responsible for continued enhancements of operational effectiveness while building relationships with key internal and external stakeholders.

A Day in the Life:

• Manages and leads the overall care management activities and day to day operations of a successful member centric care management team ensuring program activity that achieves strategic goals and objectives.
• Builds a department environment and culture that creates and maintains high performing teams with strong employee engagement.
• Facilitates effective multi -disciplinary teamwork within the department to enhance member care and program performance.
• Design, develop, and implement innovative projects related to care management initiatives that may encompass cross functional and strategic partners.
• Acts as a clinical, care management, and business case consultant for leadership as they relate to case/disease/utilization management.
• Coordinates the development, revision and implementation of care management policies and procedures.
• Assures consistency in processes and function across teams auditing and solid business practices.
• Assure compliance with state and federal regulations, accreditation requirements, contract agreements, and performance guarantees and participates and/or leads with on-site account and provider meetings.
• Excellent communication with members, providers, management, and customers to facilitate success of member and program outcomes, department objectives, and corporate strategic pillars.
• Cultivates strong working relationships across the enterprise to promote successful execution of care management programs and key initiatives.
• Ability to analyze data, conduct root cause analysis, and recommend strategies for pilots, projects, and trends for care management initiatives.
• Manages the department including interviewing and hiring employees following required EEO and Affirmative Action guidelines and ensuring employees receive the proper training.
• Conducts performance evaluation, and is responsible for managing employees, including skill and career development, policy administration, coaching on performance management and behavior, employee relations and cost control.

Nice to Have:

• 5 years' experience within insurance or health care setting in case/disease or utilization management
• Bachelor's or Master's degree in health care, business administration, or education preferred

Required Skills and Experiences:

• Registered nurse or licensed behavioral health clinician (i.e., LICSW, LPCC, LMFT, LP) with current MN license and no restrictions or pending restrictions
• 7+ years of related professional experience. All relevant experience including work, education, transferable skills, and military experience will be considered.
• If a leader of Case Managers, CCM Certification or ability to obtain within 3 years of starting in the position is required.
• 3 years leadership experience leading people, projects, products, or operations
• Strong leadership ability to drive results and excel in a collaborative, matrix environment with measurable outcomes
• Excellent organizational, change management and time management skills
• Well-developed written and oral communication skills with the ability to explain complex information clearly and convincingly
• Broad knowledge of managed care and state/federal health insurance regulations
• Demonstrated skill and experience in developing highly effective clinical teams
• Strong leadership ability, proven skills in critical thinking and ability to pursue goals with tenacity and sense of urgency
• Demonstrated ability to drive projects resulting in strategic and quality outcomes

Make A Difference

Blue Cross is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, gender expression, or any other legally protected characteristic.

Reasonable Accommodation for Job Seekers with a Disability: If you require reasonable accommodation in completing this application, interviewing, completing any pre-employment testing, or otherwise participating in the employee selection process, please direct your inquiries to

All roles require a high school diploma (or equivalency) and legal authorization to work in the U.S.

Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association.

Blue Cross and Blue Shield of Minnesota is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, or any other legally protected characteristic.