Resp & Qualifications
PURPOSE:
The Care Management Supervisor supervises, directs and coordinates the activities of Inpatient Management Clinical Navigator RNs. Utilizes MCG to act as a resource for the nurses to conduct concurrent review for medical necessity and appropriate level of care for Commercial and Government lines of business. Develops and reviews Inpatient Management standards, program criteria, policies, and procedures to ensure quality of care and manage health care costs. We are looking for an experienced Registered Nurse and people leader with UM/CM experience living within the Washington DC and/or Virginia area. The incumbent will be required to go to our assigned onsite hospitals and will be expected to come into our CareFirst locations periodically for meetings, training and/or other business-related activities. Bilingual - fluent in Spanish a big plus!
ESSENTIAL FUNCTIONS:
- Supervises Inpatient Clinical Navigator team members. Develops and leads team. Provides oversight and training as needed to increase knowledge and ensure the associates comply with policies and procedures, achieve individual and departmental goals. Supports the Manager of Inpatient Management.
- Oversees associates conducting care coordination activities including concurrent review utilizing MCG. Collaborates with CareFirst medical directors and participates in internal case rounds/discussions to determine appropriate course of action and level of care for a smooth transition to the next level of care or home. Applies sound clinical knowledge and judgment when assisting the Clinical Navigator throughout the review process. Follows member benefit contracts to assist with benefit determination.
- Assists the Manager and Director with the development, design, and implementation of new Inpatient Management programs and initiatives. Evaluates annual plans and Inpatient Management initiatives to meet evolving needs in the organization, competitors and marketplace.
- Collaborates with physicians, nursing and hospital discharge planners and leaders to ensure service expectations are being met.
SUPERVISORY RESPONSIBILITY:
This position manages people.
QUALIFICATIONS:
Education Level: Bachelor's Degree in Registered Nursing Experience OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Licenses/Certifications Upon Hire Required:
Health Services\RN - Registered Nurse Active State Licensure and/or Compact State Licensure.
Experience: 5 years experience in Utilization Management or Case Management at CareFirst BlueCross BlueShield, or similar Managed Care organization or hospital. Demonstrated leadership skills.
Preferred Qualifications: Knowledge of MCG; 2 years supervisory experience.
Knowledge, Skills and Abilities (KSAs)
- Ability to communicate effectively verbally and in writing.
- Knowledge of health benefits industry, products, trends, consumer market, and competitive intelligence.
- Knowledge and proficiency in use of metrics and measures in managing programs and services.
- Strong organizational skills to manage multiple projects, issues and priorities.
- Basic understanding of the strategic and financial goals of a health care system or payor organization, as well as health plan or health insurance operations (e.g. networks, eligibility, benefits).
- Knowledge of managed care principles and concepts including Health Plan Employer Data and Information Sheet (HEDIS) and knowledge of the standards of practice for case managers.
- Ability to mentor and coach associates to accomplish goals, provide objective evaluation of associate performance, and implement strategies to improve individual and team-based performance as needed.
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Salary Range: $79,632 - $164,241Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Department
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
PHYSICAL DEMANDS:
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
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