[Hiring] Mgr, Post Service Clinical Claims Review @Horizon Blue Cross Blue Shield of New Jersey

Role Description

This position is responsible for the design, development, coordination, implementation and outcomes of Plan Medical and Reimbursement Policy, Clinical Coding, Post-service Claims Reviews and Appeals, development, expansion and application of all Departmental Analytic Tools, and oversight of Special Projects spanning all Horizon Commercial, Medicaid and Medicare products. Areas of responsibility cross multiple disciplines including Clinical, Clinical Coding, Operations, Configuration, Primary and Secondary Editing, Communications, Pharmacy Management, Legal, Quality Management, and Payment Integrity. This role continually assesses opportunities for performance and quality improvement through:

• Direct Medical Cost Savings
• Administrative Cost Savings
• Optimizing operational efficiency and automation via platform integration
• Application of Artificial Intelligence
• Modification of Evidence Management Module (EMM)
• Integration of Claims Policy teams with Claims Policy Operations

Qualifications

• Requires High School Diploma/GED
• Bachelor’s degree from an accredited college or university preferred
• Bachelor's degree preferably in Nursing or related Clinical Healthcare field
• Five to ten (5-10) years of relevant experience
• Minimum of ten (10) years of experience in healthcare and clinical operations
• Minimum of five (5) years supervisory experience
• Experience managing multiple projects and complex programs involving cross-functional teams
• Minimum of ten (10) years management experience in healthcare management, clinical coding, and operations
• Five (5) years experience in complying with regulatory standards such as NCQA and CMS regulations
• Active Unrestricted RN License Required

Requirements

• Directs and manages operational functions within Post-service Claims Reviews, Clinical Coding, Reimbursement Policy, Departmental Analytics, and Clinical Inquiry Team
• Provides leadership emphasizing process improvement, implementation, performance, and quality improvements
• Builds relationships with internal and external partners and vendors
• Oversees coordination, development, and implementation of Clinical Coding and integration into Medical and Reimbursement policies
• Leads quality initiatives and activities
• Develops and leads Medical Policy Department performance and quality evaluations
• Ensures timely identification of problems and correction of deficiencies
• Participates in internal committees for policy and process development
• Ensures staff compliance with regulatory requirements and best practices
• Manages, develops, and trains staff; conducts annual performance reviews
• Participates in special projects as assigned by ACMO

Benefits

• Comprehensive health benefits (Medical/Dental/Vision)
• Retirement Plans
• Generous PTO
• Incentive Plans
• Wellness Programs
• Paid Volunteer Time Off
• Tuition Reimbursement