Manager Medical Management RN - Clinical Review

With more than 7,000 employees, we are the largest health insurance company in Michigan. We offer an exciting work environment with a diverse group of employees. Our goal is to make health insurance easier for our members. We want to transform the industry and become a resource that people can trust.

Southfield, MI

Blue Cross Blue Shield of Michigan

When you think of <a href="" target="_blank" rel="noopener noreferrer">Blue Cross Blue Shield of Michigan</a> for health insurance, you can know you&rsquo;re getting much more. We're a company founded on a tradition of affordable, quality health care for everyone, improving the present and investing in the future.&nbsp;<br /><br />We offer:<br />Plans for employers and individuals that meet today&rsquo;s needs, budgets and lifestyle<br />The largest network of doctors and hospitals in the state<br />Lower health care costs Higher quality health care<br />Award-winning diversity practices<br />Grants and programs that promote better health throughout Michigan<br /><strong><br />Mission:&nbsp;</strong>We commit to being our members&rsquo; trusted partner by providing affordable, innovative products that improve their care and health.<br /><br /><a href="" target="_blank" rel="noopener noreferrer"><strong>Click here</strong></a> to learn more about our commitment to our Social Mission, view company updates and reviews, and view our awards &amp; accolades.<br /><br />For Application Timeline &amp; Selection Process:&nbsp;<a href="" target="_blank" rel="noopener noreferrer">Click Here</a>. Learn more about your options as an external candidate. <a href="" target="_blank" title="BCBSM" rel="noopener noreferrer">Click here</a> to view open positions.

keywords: position summary,teamwork,support,quality assurance,medical,administration,network,performance,medical,management,experience,leadership,compliance,benefits,nurse,degree


Competitive Total Compensation Package

Overview: <div>Counsel, coach, mentor, support and assume responsibility for the day-to-day function of the Medical Management. Case Management Team, and/or Compliance &amp; Performance Improvement.</div>
Responsibilities: <ul> <li>Lead, coordinate and monitor all team activities.</li> <li>Ensure adequate staffing and service levels through the use of management techniques including monitoring production statistics and performance metrics.</li> <li>Provide hands-on support to the team as required.</li> <li>Responsible for selecting staff, conducting performance evaluations, counseling, coaching and administering discipline.</li> <li>Evaluate staffing needs, which includes leading, training and developing team members. Maintain team member relations.</li> <li>Support, recognize and provide Performance feedback to team members.</li> <li>Collaborate with Quality Improvement Coordinator to identify individual and team quality issues and develop and communicate corrective action requirements.</li> <li>Maintain professional relationships with provider community.</li> <li>Working closely with Network Management, analyze PCG utilization trends against established metrics to identify opportunities for improvement.</li> <li>Meet with PCG Administrative staff to review utilization trends and reports.</li> <li>Assist in identifying provider reporting needs.</li> <li>Support department initiatives.</li> <li>Manage project assignments.</li> <li>Represent the Medical Management department by active participation in cross-functional work teams and meetings with other departments within BCN, BCBSM and other organizations.</li> <li>Make recommendations for improvements in department workflows, processes and policies. Lead implementation of new work flows, processes and policies.</li> <li>Act as an information and problem solving resource for team members, physicians, hospital and other BCN departments.</li> <li>Interact with Medical Director or Physician Advisors as required for case resolution.</li> <li>Provide reports for management and peers as necessary.</li> <li>Coordinate in-services, meetings and communications with other internal and external parties as appropriate.</li> <li>Coordinate and ensure the appropriate flow of information to and from the Team, other Teams in the department, and other departments.</li> <li>Promote and engage in positive and constructive daily teamwork, participate in after hours call schedule and perform other duties as needed.</li> </ul>
Requirements: <ul> <li>Registered Nurse with unrestricted current Michigan license or Bachelors' degree in nursing, health care or business administration or related field required. Masters degree preferred</li> <li>Case Management Certification preferred</li> <li>Three (3) years of supervisory experience. Leadership experience with increasing responsibility may be considered on an exception basis.</li> <li>Five (5) years of acute patient care with broad clinical background required.</li> <li>Two (2) years utilization management, discharge planning, case management or quality management experience required.</li> <li>Minimum of one (1) year of experience in a managed care environment strongly preferred</li> <li>Leadership and management experience in a changing environment strongly preferred.</li> <li>Managed Care philosophy, policies, and procedures.</li> <li>Clinical criteria/guidelines for appropriateness, setting/level of care, and concurrent patient management.</li> <li>Medical Management processes across the continuum of care preferred.</li> <li>Standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing.</li> <li>Disease processes and recognition of their distinct cost patterns and unique range of available therapies and interventions.</li> <li>Current medical practices using alternative care settings and levels of service- home care.</li> <li>Case management and disease state management preferred.</li> <li>Medical terminology and ICD-9 and CPT coding required.</li> <li>BCN HMO and BCBSM POS benefits and program requirements as relates to medical management preferred.</li> <li>State and Federal HMO regulations preferred. General claims processing preferred.</li> <li>Demonstrated strong leadership, management and delegation</li> <li>Excellent written and verbal communication skills required</li> <li>Demonstrated strong problem-solving, analytical and decision making ability</li> <li>Superior conflict management skills allowing for the management of complex issues with effective diplomacy</li> </ul> <div id="gtx-trans" style="position: absolute; left: -594px; top: -20.0139px;">&nbsp;</div>