Clinical Manager

The Role

The Clinical Manager will be leading and overseeing the utilization management team, including but not limited to operations, executing policies and procedures, and provide associate development and performance management. The Clinical Manager is responsible for monitoring and achieving group metrics, such as cost and risk and ensuring continuous quality and improvements.

Key Responsibilities:

• Implement strategic and operational goals for the UM group; implement and monitor supporting plans
• Oversee the UM group, providing group communications and issue escalation / resolution support
• Maintain awareness, attitude, knowledge, and skills to work effectively with a culturally and demographically diverse population
• Serve as a mentor and advisor to UM's as they work through complex or particularly unique cases
• Become an expert of BCBSMA's products, benefits, healthcare delivery system, accreditation, regulatory requirements, and community resources
• Interpret, evaluate, and clearly document complex medical information using a directive and focused approach in order to identify relevant and actionable conditions, circumstances, and behaviors
• Meet deadlines, and deliver expected outcomes with appropriate sense of urgency
• Build effective relationships internally and externally, in person and virtually, in order to facilitate professional and business goals
• Effectively negotiate clinical operations environment; Manages clinical and non-clinical resources effectively (e.g., cost, productivity)
• Maintain knowledge of all clinical areas and specific member population
• Responsible for staff management and development including, recruiting and rewarding staff, setting performance expectations, and assessing, monitoring, and counseling staff regarding individual performance
• Articulate performance expectations and establish ongoing training programs for utilization management associates to achieve these expectations
• Provide management and direction to ad-hoc projects requested by senior management
• Track, analyze, interpret, and report regularly to leadership on UM group performance metrics
• Conduct audits to ensure productivity and performance are meeting or exceeding performance expectations; implement plans to address performance gaps
• Adherence to program, departmental and organizational performance metrics
• Foster clinical excellence by promoting and participating in educational opportunities

Key Qualifications:

• Managing in a Clinical Operations Environment (manages clinical and collaborates with non-clinical resources effectively; facilitates staff and team engagement in and accomplishment of clinical, business, and service goals in order to achieve organizational objectives)
• Knowledge of specialized subject matter (demonstrates the use of the right resources and application of the correct policies in order to support clinical determinations and administration of benefit based on product, segment, account, and clinical specialty program needs and objectives)
• Focus (ability to identify and manage to key, high-leverage information, tasks, and events)
• Consistency (ability to facilitate staff adherence to identified workflows, plan requirements, clinical guidelines, to drive sound, objective decisions)
• Negotiation (ability to resolve disputes and craft outcomes that address competing interests while achieving business objectives)
• Call management (ability to structure staff workflows that drive telephone conversations that ensure value in every contact, achieve the desired objectives for placing the call, and are efficient and professional)
• Clinical Management (ability to design workflows, identify processes, and facilitate consultative discussions that enable team members to conduct clinical assessment, clinical review, and management of an end to end episode of care)
• Productivity (ability to prioritize and manage assigned workload to accomplish full slate of targeted activities)
• Comfort and proficiency with the use of computers and technology (ability to navigate computer applications quickly and effectively, key in data proficiently in real time during phone calls, work effectively with the phone system, and quickly learn, and effectively work in, a variety of media)

Education and Experience:

• Active licensure in Massachusetts is required, appropriate to position (RN, PT, CCM, LICSW, LMHC, BCBA) Licensure in additional states a plus; any restrictions against a license must be disclosed and reviewed.
• For Registered Nurses Only: A bachelor's degree in nursing (BSN) is required; Master's degree, preferred.
• Minimum 3-5 years of RN supervisory and/or management experience, desirable
• Knowledge in the utilization management process, programs, services, business implications, trends, and policies
• Critical thinking & problem-solving skills
• Adaptability, flexibility, and self-discipline
• Exceptional communication, writing, presentation, and negotiation skills
• Proficiency with Information Technology systems
• Bilingual, a plus

#LI-Remote

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.