RN Clinical Provider Post Service Review Manager

Department Summary: The Federal Employee Program (FEP) Department is a full business unit comprised of approximately 140 associates. It encompasses a member and provider call center, provider correspondence and appeals, clinical review, member correspondence and reconsiderations, enrollment, claims processing, audits, compliance, quality assurance, documentation and a systems and implementations team. FEP is BCBSMA's single largest account

Position Summary: The RN Clinical Provider Post Service Review Manager , led by a Registered Nurse, is responsible for a team of provider correspondence associates who research and respond to provider inquires and appeals, build cases, and perform claim adjustments in a dual system environment. This manager also has direct oversight to a team of clinical (RN) reviewers and offers guidance on clinical and coding integrity reviews that are required by the FEP Association to ensure compliance and accurate case/claims processing

This leader must demonstrate the attributes and ability to empower associates to achieve goals, the capacity to excel in a fast paced and changing environment and meet the expectations of internal and external customers. This position requires the ability to think strategically and conceptually across all operational and support teams. It requires in-depth functional, operational, and regulatory knowledge along with an appreciation that cross-functional interdependence is essential to effective performance

To be successful in this role, the manager must have a strong understanding of the dual platform claim processing system, Federal government regulations and NCQA requirements which is required to identify opportunities to mitigate audit risk and/or implement innovative solutions for processing efficiencies. The role involves close partnership with key business partners, such as the physician review unit, health and medical management, network management, business operations, payment policy, legal, special investigations unit, audit and risk management, facility and professional reimbursement strategy/payment integrity teams in order to operationalize successfully, meet key performance indicators, develop strategic initiatives, and implement enhanced processes to consistently move the business forward.

The leader will also participate in Corporate, FEP Association and FEP Operations Center projects to advance team functionalities. This position reports to the Associate Director of FEP Operations.

Key Accountabilities:

• Lead and motivate a team by creating a professional environment that demonstrates commitment, high levels of performance, continuous improvement, and ownership
• Offer opportunities for continuous learning and associate engagement
• Build bench strength to secure talent
• Positively influence overall Program Performance
• Full understanding of team responsibilities, support workflow development and properly assign and prioritize tasks
• Provide direct oversight to meet/exceed key performance metrics
• Manage performance/productivity and offer day to day support
• Understand and operationalize the rules and regulations set forth by FEP, NCQA and ACA
• Demonstrate understanding of mandated FEP Operations Center (FEPOC) system software mandated release and ad hoc changes to identify potential impact to members and providers and ensure team processes/workflows align and are successfully communicated
• Provide timely feedback and ongoing coaching and mentoring for all associates
• Support clinical and administrative processes outlined by regulations
• Meet with team members on a regular basis to ensure a synergistic and productive environment, provide performance and development feedback and opportunities

Qualifications (knowledge/skills/abilities/behaviors):

• Proven leadership skills
• Ability to foster an environment of teamwork, openness, trust, respect and acceptance
• Ability to recognize problems, effectively strategize and recommend innovative solutions and decisions around complex situations within a fast-paced operational environment
• Effective listening, organization, inventory management and prioritization skills
• Demonstrate flexibility to meet demanding priorities and deadlines
• Collaborate with a team of professionals, both internal and external, to provide excellent service to our members and providers
• Demonstrate strong presentation and communications skills (verbal and written). Ability to interact and communicate effectively with all levels within and outside of the organization as well as tailor messages to specific audiences
• Demonstrate ability to develop strategic action plans, prioritize and execute tasks that contribute to the overall goals and vision of BCBSMA and the FEP Association
• Demonstrate strong analytical skills and initiative to recognize problems, recommend innovative solutions and implement those solutions for greater efficiencies
• Acquire and retain talent through effective recruiting, onboarding, management, and succession planning
• Establish and maintain partnerships throughout BCBSMA and with the FEP Association and FEP Operations Center
• Ability to work independently, collaboratively, and cross functionally with all levels of the organization

Education/Relevant Experience:

• Active professional Registered Nurse in MA required. Bachelor's degree preferred
• Experience with the Provider appeals process required; coding and claims knowledge preferred
• 4+ years of experience in a management level position/operational leadership experience preferred
• FEP (Federal Employee Program) and/or experience working within a regulatory space preferred
• Ability to demonstrate proficiency with multiple Information Technology systems
• Working knowledge of claims systems is a plus
• FEPDirect experience a plus
• Experience working within a regulatory space preferred
• Proficient with Microsoft office suite of applications and tools

High school degree or equivalent required unless otherwise noted above

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that theconfidence gapandimposter syndromecan prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.