Team Lead Medical 9/15/2016
Blue Cross and Blue Shield of North Carolina
JOB DESCRIPTIONAPPLY JOB DESCRIPTION
Utilizes clinical expertise to interpret medical policy and medical criteria and educates/coaches staff appropriately according to their job roles and functions. Conducts clinically based discussions with nursing and medical staff (both internal staff and external customers). Leads teams by encouraging them to take ownership of their work processes and understand their role within the company. Helps teams to understand high-level business objectives and how their work is essential to the achievement of these objectives. Manages performance of team members and delivers timely and appropriate performance feedback and training.
* Manages day-to-day business area activities, provides leadership, coaching and training to team members, sets clear goals and expectations and manages performance as needed.
* Creates a positive work environment that fosters teamwork, empowerment, accountability, and superior customer service.
* Acts as a medical and technical resource for team members and other departments, providing assistance/guidance on clinical and/or system issues, benefits, and work processes and procedures specific to departmental needs.
* Identifies trends, determines root causes, and takes action to resolve issues and initiate necessary process and procedural changes to improve internal and external customer satisfaction.
* Ensures all departmental and clinical reports and necessary reviews are completed in a timely manner.
* Maintains accountability for achieving targeted results and communicates regularly with organization leadership regarding workloads, issues, projects, monitoring of team performance and staffing needs.
* Leads special projects and/or represents the department on corporate projects that require independent, sound decision making and broad based understanding of effects on the department as a whole.
* Responsible for the application and compliance with all regulations, standards or other regulatory requirements applicable to departmental operations. Formulates corrective action plans to address any areas of non-compliance.
* Must maintain current knowledge in applicable clinical areas, standards and certifications (where required) and keep abreast of trends related to the health insurance industry (i.e. CPT, HCPCS, ICD-9, and ICD-10 coding, etc).
* Facilitates meetings and conducts formal presentations for staff and/or cross functional or customer groups as needed.
* Serves as liaison between Medical Review and the medical directors supporting the department.
* Performs activities that relate to Utilization Management delegated oversight including on-site visits to delegated entity.
* Manages consistency review process for all clinical staff. Results of the reviews are provided to individual staff for input into performance evaluations. Collaborates with manager to identify trends within the department and to plan additional training.
Senior Segment Programs - Case and Utilization Management
* Promotes and encourages staff to utilize essential elements of the nursing process in their job functions: assessment, planning, implementation, coordination, monitoring, and evaluation.
* Serves as a liaison between medical directors, key operational areas and staff as necessary to identify and resolve issues.
Commercial - Case and Utilization Management
* Oversees the identification of cases, development of early and aggressive discharge plans and implementation of discharge plans, integration of activities, and communication with providers, patients, employers and Plan staff to include Episodic Care Managers and Case Managers.
* Develops in conjunction with management and the Plan s medical directors, guidelines, policies, and procedures to facilitate provision of appropriate high quality, cost effective medical care to members within the context of the members benefit plan.
* Ensures scheduling of rounds with staff members and Medical Directors. Attends rounds as requested to evaluate efficiency of the process and acts as a medical resource for team members and other departments. Serves as liaison between all staff and the medical directors supporting the department.
FEP - Case and Disease Management
* Oversees integration of activities, and communication with providers, members, employers and Plan staff to ensure timely utilization of community and health care resources.
* Develops in conjunction with management and the Plan s medical director, guidelines, policies, and procedures to facilitate provision of appropriate high quality, cost effective medical care to members within the context of the members benefit plan.
* Serves as liaison between Case/Disease Management and the medical directors supporting the department.
Education, Case Management, Utilization Management, Call Center Commercial
* Responsible for new employee training and orientation to the business unit processes and systems and monitors the quality and productivity performance of new employees until desired levels of quality and productivity have been achieved.
* Assesses relevant training needs for all staff and individuals, produces training materials and strategies and manages the training delivery, measurements and appropriate follow up.
* Presents and facilitates training and development programs utilizing various instructional methodologies and media; allowing sufficient time for practice and facilitating group interaction to attain stated objectives
* RN with valid NC license is required.
* 3 years previous full time direct clinical nursing experience or 3 years in the health insurance industry in utilization management, managing health conditions, understanding medical criteria, medical guidelines, medical policy, and NCQA and DOI, Medicare/CMS regulations.
* Demonstrated leadership skills (i.e. training, mentoring, coaching or assisting peers with issue resolution) or previous experience in a leadership role is required.
* Knowledge of Windows and Microsoft Office required.
* For Team Leads that supervise Commercial Case Managers: Certified Case Manager (CCM) certification is required within 2 years of obtaining the role of Team Lead. Team Leads in existence as of 4/1/10 will have two years to obtain certification.
* Experience in a health insurance environment preferred
* Knowledge of medical policy and healthcare claims administration is preferred.
* Keeps abreast of medical knowledge and care patterns, regulatory and governmental rules and regulations, and of BCBSNC policies related to business area needs.
* Takes ownership of personal development and continuous learning by networking with peers, joining relevant associations, staying abreast of current industry trends, etc.
* Medical management and sound decision making skills.
* Must possess the ability to build effective working relationships with providers, members, employers, and BCBSNC staff.
* Commitment to high quality customer service.
* Coaching skills and the ability to give, constructive feedback, and develop employees.
* Demonstrated ability to promote and support teamwork and team decision-making.
* Ability to build consensus and form partnerships with various levels of staff within and across an organization.
* Excellent negotiation, decision-making, and relationship-building skills.
* Excellent oral and written communication skills.
* Demonstrated analytical thinking skills.
* Ability to identify issues and recommend and implement solutions.
* Ability to make sound and independent business decisions in often high-pressure situations..