Dir, BH Medicaid Admin & Clinical Ops
Full Time
Newark, NJ 07105
Posted
Job description
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware
Job Summary:
The Dir, BH Medicaid Admin & Clinical Ops is clinical leader in the Medicaid plan focusing on integrating member care, clinical coordination, leading the development, implementation and ongoing monitoring of program and quality initiatives to address the needs of Horizon BCBS of New Jersey HNJH members behavioral health needs. This includes general Medicaid, DSNP, and MLTSS members and providers. To be the lead representative of the plan in key behavioral health initiatives collaborative with State government as well as day to day operation management for all clinical processes. This includes providing leadership and oversight of the overall clinical and non-clinical operations as well as working with multiple partners to ensure state compliance with and inclusion of HNJH strategic initiatives in State contracts. This role is responsible for assisting all functional areas with Medicaid responsibilities to establish, interpret and implement, new and existing company policies and procedures. This position is also responsible for the adherence and maintenance of the regulatory agency requirements and for analyzing utilization, performance trends, and quality of health care to ensure timely and cost effective delivery. This role works in close partnership with Medical Management, Finance, Quality Management, Corporate Compliance, Legal and Government Affairs Areas, Business Services and Operations, and Provider Contracting and Servicing to ensure State compliance with and inclusion of HNJH strategic initiatives in State contracts.
Regulatory Affairs BH:
- Cultivate, drive and maintain critical strategic business partnerships with regulatory agencies (Department of Human Services, Department of Banking & Insurance, Department of Health, Department of Children-s & Families, and CMS), industry associations (Blue Cross Blue Shield Association, Association for Community Affiliated Plans, Medicaid Health Plans of America, and NJ Association of Health Plans), and other external stakeholders.
- Receives, oversees and/or responds to any complaints or escalated issues received from the DOH, DHS/ DMAHS as well as State and Congressional legislators and drives resolution and timely response.
- Assists other departments in understanding and complying with regulatory requirements by researching regulations and assisting as needed in developing procedures to comply with, and draft responses to, queries from regulatory agencies.
- Responsible for submission of required reports to Division and monitors administration of benefits and performance of implemented Behavioral Health programs.
Reporting:
- Development, Monitoring, and delivery of BH reporting deliverables to the state related to key initiatives and/or state inquiries.
Regulatory Audit Policy & Procedure:
- New program policy & procedure build with regulatory, legal review and committee review for approval.
- Annual review of Medicaid policies and recertification by committee.
- Subject matter expert to assist and participate in state audits.
Clinical Operations:
- Works in partnership with clinical operations, claims, network, regulatory affairs, and analytics teams to ensure Medicaid client satisfaction and appropriate level of service delivery.
- Recognizes and identifies opportunities to improve the quality of Medicaid care/services and initiates steps and activities to advance outcomes.
- Represents department on various Medicaid Plan Task Forces/Committees.
- Develops new Medicaid programs and implements policies, procedures, and ad hoc reports.
- Interfaces with other teams and plan areas to assure consistent application of policies and procedures and to facilitate inter- unit/department projects.
- Represents the Plan with external customers, providers and external agencies and represents the unit on corporate issues and/or in the event of Director's absence.
- Creates and champions an atmosphere within the Medicaid teams which fosters open communication, increase employee engagement, teamwork, ownership, and a collaborative cross-departmental environment to implement, optimize and share continuous improvement processes.
- Determines Medicaid BH departmental program expansion needs and conducts ongoing development plan to assure that the future Medicaid expansion projects as well as new program implementations can be successful.
Education/Experience:
- Requires a Nursing degree, or a Bachelor's degree in a Behavioral health related field.
- Requires minimum of five (5) years’ experience in a healthcare-related field with a focus on Medicaid regulatory and benefit management knowledge related to behavioral health preferred.
- Requires minimum of five (5) years broad clinical experience.
- Requires minimum of three (3) years direct supervisory experience or demonstrated supervisory experience leading teams in a matrix management environment.
- Prefers professional certification in a clinical specialty as appropriate to the business unit.
Additional licensing, certifications, registrations:
- Active Unrestricted NJ LCSW, LMFT, LPC, or RN License Required.
Knowledge:
- Requires strong knowledge of functional tasks performed within department.
- Requires knowledge in the principles of risk management and quality assurance.
- Requires knowledge of NCQA standards.
- Requires knowledge of State Mandates and Regulations.
- Requires knowledge of regulatory bodies and their processes.
- Prefer knowledge of Plan products, applications, policies, procedures and systems.
Skills and Abilities:
- Requires excellent organizational skills and ability to set priorities
- Requires excellent oral and written communication skills
- Requires excellent presentation skills.
- Requires comprehensive leadership and decision-making skills.
- Requires strong analytical, problem solving, and critical analysis skills to report findings in a complete, succinct and accurate manner.
- Must be proficient in the use of personal computers and supporting software in a Windows based environment including MS Office products (Word, Excel, PowerPoint) and Outlook; should be knowledgeable in the use of intranet and internet applications.
Travel % (If Applicable):
- Travel required to other Horizon offices, provider locations and/or for oversight of remotely located workforce members in accordance with Company needs.
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.
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