Manager Medical Review - Commercial Services, Remote

Job Summary:
Leads a multi-disciplinary team to resolve authorization/referral requests and clinical claims and inquiries within regulatory and accreditation compliance standards.

Resolving clinical claims and inquiries in a manner that is intended to enhance member and provider experience and effectively manage impacts to medical costs. Ensures timely notification of authorization/medical review requests to members and providers, with explanation of appeal and peer-to-peer review request processes. Educates providers regarding authorization and medical review processes to facilitate timely and appropriate decisions on behalf of members. Collaborates with IT, Network, Availability, Clinical Enablement, Vendor Managers, Service Organization, and other areas of the company to ensure optimal and efficient resolution of medical review requests. Responsible for meeting and reporting operational metrics related to clinical review, including identification of trends, potential leakage, and opportunities for process improvements. Leading the FEP/PEP Pre and Post-Service team to meet company goals, regulatory and legislative mandates and operational objectives through standardized clinical processes;

Essential Functions:

• The essential functions listed represent the major duties of this role, additional duties may be assigned. Effectively manages authorizations, claims and inquiry inventories between various divisions of the pre and post service medical review departments.
• Develops and maintains consistent policies, workflows, and processes implementing best practices, throughout the post-service departments.
• Develops a partnership with the Service Organization to ensure accurate claim payment and reduced re-works.
• Develops strong business relationships within the Delivery System to allow BCBSF realize our value proposition to network physicians and providers.
• Ensures adherence with group specific requirements and compliance with regulatory agencies; ensures adherence to policy and procedure within the department.
• Leads department members to meet individual and team and operational goals and objectives (e.g. telephone, fax, held authorizations, inventories, etc) and builds an effective team.
• Provides guidance and clarification of clinical and non-clinical standards to clinical and non-clinical staff, and effectively manage among the regional department
• Leads team to identify, implement and monitor continuous quality improvement initiatives (CQI) for standardized clinical and non-clinical processes.

Required Experience:
5+ years related work experience. Experience Details:
2+ years direct supervisory/management experience
Related Bachelor's degree or additional related equivalent work experience
Occasional travel required. 10% within the state of Florida

Leadership skills (communicating, inspiring, empowering, resolving conflicts, etc)

Knowledge of general management practices (organizing, planning, controlling, budget/expenditure control, HR program/practices) in a participative environment Excellent written and verbal communication skills with the ability to communicate effectively with all levels of an organization and diverse audiences

Proven ability to build relationships within the business area, across the organization, and external to BCBSF

Proven ability to resolve issues and barrier Continuous improvement (CI) processes (Six Sigma or other TQM methodologies and tools)

Knowledge of and ability to coach on the following service tools, processes, and programs:

Health care regulatory requirements; Excellence in customer service; Knowledge of Microsoft Office including Outlook

Preferred Qualifications:

Knowledge of CMCA, CCMS, Siebel
Master's degree Advance degree in related field
Active Florida RN license

General Physical Demands:
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

What We Offer:
As a Florida Blue employee, you will be at the heart of GuideWell's vision - to lead the nation in transforming health through compassionate, connected, and technology-enabled care that delivers personalized value and empowered living.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:

• Medical, dental, vision, life and global travel health insurance;
• Income protection benefits: life insurance, short- and long-term disability programs;
• Leave programs to support personal circumstances;
• Retirement Savings Plan including employer match;
• Paid time off, volunteer time off, 10 holidays and 2 well-being days;
• Additional voluntary benefits available; and
• A comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Annualized Salary Range: $84,500 - $137,300

Typical Annualized Hiring Range: $84,500 - $105,600

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.