Clinical Team Lead/Lpn - Preauthorization

Position Description:

Capital Blue Cross has an exciting opportunity for a Clinical Team Lead-Preauthorization to join our award-winning organization. Since 2014, Capital Blue Cross has scored higher than all health insurance providers publicly measured in the American Customer Satisfaction Index (ACSI) and is proud to be named a Best Places to work in PA, Harrisburg Magazine’s Simply the Best, and Highest Member Satisfaction J.D. Power Award.

The Clinical Team Lead oversees the daily operation of the assigned unit, including but not limited to: providing support of the staff, both office and home based, of their daily activities, assessment and adjustment of assignment based on unit needs, adherence to established policies and desktop procedures, audits for accreditation and regulatory compliance and departmental performance metrics, evaluation of productivity and program performance reports, facilitation of ongoing staff development, and general departmental oversight activities. -This position monitors changes, corrections, and clarifications in applicable regulatory/accrediting body requirements and makes adjustments to the operations of the clinical teams based on these changes, corrections and clarifications.-In addition this position coordinates project implementation for Utilization Management. On an as needed bases: assembles workgroups and/or coordinates project meetings to facilitate timely assessment, planning, implementation and evaluation of assigned projects.

Responsibilities and Qualifications:

• Assists the manager in planning and development of the concurrent review program.
• Carries out responsibilities in timely and accurate fashion, and in accordance with corporate and departmental policy/procedure.
• Delivers comprehensive, accurate report documents as necessary to support accreditation and regulatory requirements, including reports necessary to support NCQA, DOH, and CMS review processes and internal quality improvement activities (i.e., Quality Management Program Evaluation, Clinical Management Work plan Evaluation, and Medical Management Work plan Evaluation).
• Provides support to staff with ongoing activities.
• Acts as preceptor and mentor to the staff by providing regular feedback regarding their performance, through evaluation and counseling following Capital BlueCross Human Resource procedures
• Acts as liaison with key personnel within the organization and with hospitals, ancillary providers, employer groups and members.
• Participates in special projects as needed. Maintains current, accurate and organized documentation of project activities, including but not limited to, project plans, project timelines, meeting agendas, meeting minutes, etc.
• Monitors and evaluates staff compliance with established policies and desktop procedures and develops action plans as needed.
• Promotes the value of Clinical Programs within the organization and within the provider community.
• Corporate and departmental goals and priorities are incorporated into recommendations, decisions, and actions.
• Leads review meetings to facilitate multidisciplinary communication. Establishes, manages and evaluates departmental policies, desktop procedures, goals, staffing levels and caseloads, and makes appropriate changes as needed to achieve optimal outcomes.
• Keep abreast of developing trends, knowledge and skills. Analyzes available data and develops recommendations based on results, industry trends, and evidence-based research.
• Assesses and analyzes current process and makes recommendations to manager.
• Attends and participates in company and departmental meetings and training sessions as required.
• Identify strengths or weaknesses within assigned unit, including but not limited to trends, outcomes, staff productivity, and other department/organizational goals as established.
• Assists with the oversight of compliance with regulatory and accreditation standards.
• Develops and/or maintains current, accurate and organized documentation of related activities, including but not limited to, program/service descriptions, contractual requirements, program processes (desktops, related forms, policies and procedures, etc.), collaterals/marketing materials, letters and mailing materials, surveys and evaluation tools, website content and other documents as required by program structure.

Education, Certification, and Licenses:

• This position requires a current Pennsylvania LPN or RN License; a bachelor’s degree is preferred. For Concurrent Review must be RN.

Experience:

• Experience creating and presenting oral and written presentations, proposals and reports along with experience in public speaking and the ability to compose.
• Supervisory experience in a healthcare related field is preferred.
• Minimum of two (2) to three (3) years of managed care experience, specifically in utilization management and/or case management.
• Within 3 years must obtain Certified Case Management (CMM) designation or Certified Case Management Administrator designation. For Concurrent Review Certified Case Management (CCM) designation is a requirement for hire. Must have active case management experience.
• The incumbent must possess five (5) years of active clinical nursing practice.
• Experience in researching evidence-based and industry standards and requirements relevant to medical management programs.

Knowledge:

• Knowledge of managed care principles and emerging health treatment modalities.
• Knowledge of all Capital BlueCross products including coverage policies, interacting relationships and claims processing issues.
• Knowledge of regulatory requirements for Utilization Management including URAC, NCQA, Act 68, ERISA, DOH, HIPAA and CMS.
• Knowledge of current and emerging medical treatment modalities with the ability to analyze and interpret medical and benefit coverage interrelationships.

Skills:

• Self- motivated and works independently.
• Strong team skills with the ability to work and interact with management level staff both within and outside of Clinical Management.
• Excellent written, oral communication and organization skills.
• Ability to operate a personal computer (PC), including proficiency in Microsoft Word, Power Point, Access and Excel. VISIO and Microsoft Project experience preferred.
• Demonstrates tact and diplomacy when communicating with member, physician(s), and other members of the health care team.
• Anticipates and identifies problems, thoroughly analyzes available information and makes timely, practical decisions exercising good judgment.

Physical Demands:

• The employee must occasionally lift and/or move up to 5 pounds.
• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.

About Us: Capital Blue Cross is the leading health solutions and insurance company in Central Pennsylvania and the Lehigh Valley. As a partner in the community’s health for over 80 years, Capital Blue Cross offers employees excellent pay, bonus opportunities, benefits, health and wellness incentives, opportunities for career advancement and community involvement, and work-life balance. In return, every member of our workforce plays an important part in something much bigger: working together and making a difference every day to improve the health and well-being of our members and the communities in which they live.