MLTSS Supervisor, RN/SW

About the Role The position is responsible for leading the managed long‑term support and services program clinical care team in a hands‑on manner to provide exceptional service to customers and contain medical claims cost. This is accomplished through active involvement and leading of the day‑to‑day operations of a clinical care team and ensuring staff is consistent with corporate policies and procedures and complies with contractual, state and federal guidelines. Responsibilities Supervises, analyzes and coordinates the daily activities of the unit to ensure departmental productive goals are met with regards to quality, timeliness, accuracy and consistency of medical decisions. Continuously evaluates workflow issues and seeks to improve processes that impact the managed long‑term support and services department. Coordinates data collection, reviews compliance reports and identifies opportunities for service improvements. Recommends, develops and implements department policies and procedures and interfaces with other areas to ensure consistent applications. Acts as liaison between Medical Directors and staff. Develops and monitors goals for staff and provides ongoing feedback and coaching. Conducts performance reviews on an annual basis and administers salaries for the staff. Directs the employment activities of the office that include staffing, development, and training. Ensures staff meets all regulatory requirements and comprehends and complies with best practices, professional standards, internal policies, and procedures. Performs the operational duties of a specific clinical care team. Creates an atmosphere within the team that fosters open communication, teamwork, ownership, and empowerment to make decisions. Develops key performance indicators to evaluate level of service for internal and external customers. Acts as technical expert and reference point for difficult and complex matters. Facilitates the creation of service and processing innovations within the team. Shares innovations with other teams and market divisions. Assists in preparing and monitoring the budget to ensure administrative cost objectives are met. Identifies and implements cost‑saving/revenue‑generating opportunities. Interprets and executes policies for the team. Participates in special projects initiated by the Plan. Assists Manager in coordinating regulatory, quality and accreditation activities. Represents the Plan with external customers, providers and agencies. Represents the department on internal committees. Education and Experience High School Diploma/GED required. Bachelor’s degree preferred or relevant experience in lieu of degree. Two to four years of acute healthcare experience. Preference for one year of supervisory experience. Preference for one to three years of experience in the health insurance industry. Certification as a case manager preferred. Professional certification in a clinical specialty and at least three years of experience as a case manager preferred. Active unrestricted NJ RN/SW license preferred; candidates with a restricted license will not be considered. Knowledge Utilization Management (UM) and managed care principles as they relate to the CCM process and Elderly Frail /Managed Medicaid population‑based CM. Case Management/Disease Management Standards of Practice. Health care systems and medical documentation. Claims processing, contracting and enrollment. State mandates and regulations, including HIPAA and HCQA. Regulatory bodies and their processes including HCFA and DOBI. NCQA and URAC accreditation criteria related specifically to UM/DM and Case Management. Community health resources. Skills and Abilities Clearly and concisely expresses thoughts orally and in writing. Obtains the skills possessed by team members and demonstrates system technical competence. Effectively leads team members in diversified tasks. Exhibits excellent organizational skills. Exhibits excellent presentation skills. Analyzes and reports findings accurately. Proficient with computers and related software packages. Travel Minimum local travel required. Salary Range $87,300 - $119,070 Benefits Comprehensive health benefits (Medical/Dental/Vision) Retirement plans Generous PTO Incentive plans Wellness programs Paid volunteer time off Tuition reimbursement Legal Notice Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status, or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process. #J-18808-Ljbffr