[Hiring] Manager Medical Review @Florida Blue

Role Description

Leads a multi-disciplinary team to resolve authorization/referral requests and clinical claims and inquiries within regulatory and accreditation compliance standards.

• Resolving clinical claims and inquiries to enhance member and provider experience and manage medical costs.
• Ensures timely notification of authorization/medical review requests to members and providers, with explanations of appeal and peer-to-peer review request processes.
• Educates providers regarding authorization and medical review processes to facilitate timely and appropriate decisions on behalf of members.
• Collaborates with IT, Network, Availability, Clinical Enablement, Vendor Managers, Service Organization, and other areas of the company for optimal resolution of medical review requests.
• Responsible for meeting and reporting operational metrics related to clinical review, including identification of trends, potential leakage, and opportunities for process improvements.
• Leading the FEP/PEP Pre and Post-Service team to meet company goals, regulatory and legislative mandates, and operational objectives through standardized clinical processes.

Qualifications

• 5+ years related work experience.
• 2+ years direct supervisory/management experience.
• Related Bachelor’s degree or additional related equivalent work experience.
• Occasional travel required (10% within the state of Florida).
• Leadership skills (communicating, inspiring, empowering, resolving conflicts, etc).
• Knowledge of general management practices (organizing, planning, controlling, budget/expenditure control, HR program/practices) in a participative environment.
• Excellent written and verbal communication skills with the ability to communicate effectively with all levels of an organization and diverse audiences.
• Proven ability to build relationships within the business area, across the organization, and external to BCBSF.
• Proven ability to resolve issues and barriers.
• Continuous improvement (CI) processes (Six Sigma or other TQM methodologies and tools).
• Knowledge of and ability to coach on service tools, processes, and programs.
• Health care regulatory requirements; excellence in customer service; knowledge of Microsoft Office including Outlook.

Preferred Qualifications

• Knowledge of CMCA, CCMS, Siebel.
• Master’s degree or advanced degree in related field.
• Active Florida RN license.

General Physical Demands

• Sedentary work: Exerting up to 10 pounds of force occasionally to move objects.
• Jobs are sedentary if traversing activities are required only occasionally.

Benefits

• Medical, dental, vision, life and global travel health insurance.
• Income protection benefits: life insurance, short- and long-term disability programs.
• Leave programs to support personal circumstances.
• Retirement Savings Plan including employer match.
• Paid time off, volunteer time off, 10 holidays and 2 well-being days.
• Additional voluntary benefits available.
• A comprehensive wellness program.

Annualized Salary Range

• $84,500 - $137,300.
• Typical Annualized Hiring Range: $84,500 - $105,600.

Equal Employment Opportunity

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.