Supervisor, Care Management at Meridian

Job Description

Under general direction, supervise and provide clinical guidance for the day to day operations of Pre-Service Medical Review clinical staff. Maintain unit clinical workflows and policies & procedures for the authorization process to ensure compliance with contractual, regulatory and accreditation requirements. Responsible for inter-rater reliability audits of the clinical staff. Oversee the development, system configuration and notification of medical policy updates in alignment with updates from the BlueCross BlueShield Association (BCBSA) Technology Evaluation Center (TEC), Center for Medicare & Medicaid Services (CMS) and the Blue Cross of Idaho (BCI) Medical Policy Committee.

Required Experience:
* Three (3) years clinical care nursing to include acute inpatient care, outpatient care or specialty care
* Three (3) years health plan experience in utilization review, medical policy or medical review
* Three (3) years supervisory/leadership.

Required Education:
* Bachelors degree in a health services related field

Required Certifications/Licenses:
* Valid unrestricted Idaho Registered Nurse License (RN) in good standing
* Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) (or must obtain within 18 months of hire)

Required Knowledge, Skills and Abilities (KSAs):

Knowledge of:
* Medical record review
* Medical necessity criteria
* Diagnosis/Procedure coding guidelines.
* Managed care delivery systems including Medicare plans
* Reporting requirements
* Utilization management
* Quality Improvement (QI)
* National Commission on Quality Assurance (NCQA) accreditation standards
* Center for Medicare and Medicaid Services (CMS)
* HCPCS, CPT and ICD-9 coding

Skills:
* Customer service
* Organizational
* Time management
* Prioritize work
* Technical writing/business writing
* Verbal and written communication
* Detail oriented
* Microsoft Word - Basic
* Microsoft Excel - Basic
* Microsoft Outlook - Basic

Ability to:
* Give and receive constructive feedback in a team environment
* Handle questions and inquiries regarding medical decisions for staff
* Effectively monitor & maintain staff performance levels
* Research information through the Internet to include CMS websites
* Coordinate timeliness of medical policy reviews and updates as directed

PREFERRED QUALIFICATIONS:
* Blue Cross of Idaho (BCI) Commercial and Medicare Advantage benefit structures, general medical insurance , contract language and claims
* BCI and Center for Medicare & Medicaid Services (CMS) medical management programs and medical policy development process

Position reports to: Manager, Medical Review
Starting Salary (Grade 17): $61,539 - $76,924
Internal Posting Close Date: 11/15/2013
External Posting Close Date: until filled

Come work for a leading Health Insurance carrier in Idaho. To learn more about the requirements for this position, to search other employment opportunities and to apply online please visit our Web site at www.bcidaho.com/careers. We offer excellent benefits and competitive salaries, including incentive programs, 401(k), paid holidays, and much more! EEO/AA/D/V

Job Requirements

 
Country: USA, State: Idaho, City: Meridian, Company: Blue Cross of Idaho.