[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

What You'll Do

• Directs and manages the operational functions within Post-service Claims Reviews, Clinical Coding, Reimbursement Policy, Departmental Analytics, and Clinical Inquiry Team for all Horizon Commercial, Medicaid and Medicare products, and Special Projects and Initiatives.
• Provides leadership to the above teams emphasizing process improvement, implementation, performance and quality improvements through objective measurement and monetization of activities performed within this Department.
• Builds relationships with internal and external partners and vendors to collaboratively identify performance improvement opportunities and operational efficiencies.
• Oversees the coordination, development and implementation of Clinical Coding and integration into Medical and Reimbursement policies.
• Leads quality initiatives and activities and generates data to guide informed management and leadership of the Medical Policy Department.
• Develops and leads Medical Policy Department performance and quality evaluations. Implements and monitors departmental performance and quality.
• Ensures timely identification of problems and correction of deficiencies in accordance with regulatory requirements.
• Participates with internal committees in the development of policy and processes to optimize overall performance.
• Ensures staff meets all regulatory requirements and comprehends and complies with best practices, professional standards, internal policies, and procedures.
• Manages, develops and trains staff; develops and monitors goals; conducts annual performance reviews, and administers salaries for the staff.
• Provides regular timely reports on program status to the leadership team.
• Participates in special projects as assigned by ACMO.

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 or relevant field
• Minimum of five (5) years supervisory experience
• Experience managing multiple projects and complex programs involving cross functional teams required
• 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

Benefits

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