Mgr, RN Clinical Ops

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.

This position is responsible for providing leadership and oversight of the overall clinical and non-clinical operations. Assists Director in establishing, interpreting and implementing new and existing company policies and procedures. The manager is also responsible for the adherence and maintenance of the regulatory agency requirements for DOBI, NCQA, DOL, DMHAS and CMS for analyzing utilization, performance trends, and quality of health care to ensure timely and cost effective delivery ASO (Administrative Services Only) managed care accounts are a type of self-funded health plan where an employer, known as the "plan sponsor," hires a third-party administrator (TPA) or an insurance company to handle the administrative tasks of benefits and claims processing, but the employer remains responsible for paying the actual employee claims.

Manages, analyzes and coordinates the daily activities of the unit to ensure departmental goals are met with regards to timeliness, accuracy and consistency of medical decisions. Manages and directs staff to ensure overall client satisfaction, appropriate level of service delivery, quality outcomes. Recognizes and identifies opportunities to improve the quality of Care/services and initiates steps and activities to advance outcomes. Subject matter expert for multiple blue list projects, mandate office projects, task forces/Regulatory Committees. Develops and implements policies, procedures, and ad hoc reports to meet regulatory guidelines. Maintains and monitors the departmental budget to ensure administrative costs are managed. Subject matter lead for IPRO, CMS, Burchfield, NCQA audits. Identifies and implements business process improvements to identify efficiencies and cost savings opportunities. Interfaces with other teams and plan areas to assure consistent application of policies and procedures and to facilitate inter-unit/department projects. Represents the Plan with CBU with external group customers and Regulatory affairs for external agencies. Represents the unit on corporate issues and/or in the event of Director's absence. Creates and champions an atmosphere within the team, which fosters open communication, increase employee engagement, teamwork, ownership, and a collaborative cross-departmental environment to implement, optimize and share continuous improvement processes. Determines departmental budget and conducts ongoing expense management. Manages, directs, and develops staff by providing feedback and coaching. Administers performance and salary reviews for staff. Ensures staff meets all regulatory requirements and comprehends and complies with best practice methodology, professional standards, and internal policies and procedures.