Clinical Care Management Supervisor

2 weeks ago

Baltimore, Maryland, United States CareFirst BlueCross BlueShield Full time
POSITION SUMMARY:
The Clinical Care Management Supervisor is responsible for overseeing and coordinating the functions of Inpatient Management Clinical Navigators (Registered Nurses).

This role is essential in ensuring compliance with established policies and procedures to enhance the quality of care while managing healthcare expenditures.

Onsite presence at various hospitals in the Baltimore and Southern Maryland regions is required for at least three days each week, along with potential meetings at CareFirst office locations.

This position serves as a key liaison, fostering positive relationships with hospital teams to facilitate efficient transitions from inpatient care to lower levels of care or home settings.

The Supervisor will leverage their expertise in both case management and utilization management.


KEY RESPONSIBILITIES:
Supervises the Inpatient Management team and collaborates with the Manager to guide team development.

Utilizes clinical knowledge and analytical skills to evaluate clinical data, electronic medical records (EMRs), benefit contracts, and regulatory requirements to determine the appropriateness and authorization of inpatient clinical services.

Assists the Clinical Navigator in engaging with members, families, and providers to identify critical interventions, discharge planning, and coordination to address medical, behavioral, and social determinants of health, ensuring safe transitions to appropriate care levels.

Contributes to the development and implementation of new Inpatient Management programs and initiatives in collaboration with the Manager and Director.

Works alongside CareFirst medical directors and participates in internal case discussions to establish suitable courses of action and care levels.

Employs sound clinical judgment throughout the review process and adheres to member benefit contracts for benefit determinations.

Supports the Clinical Navigator in making appropriate referrals to other Care Management programs for chronic and long-term care coordination.

Collaborates with physicians, nursing staff, and hospital leadership to ensure service expectations are met.


SUPERVISORY ROLE:
This position includes management responsibilities.

QUALIFICATIONS:
Education:
Bachelor's Degree in Nursing or, in lieu of a degree, an additional four years of relevant experience is required alongside the necessary work experience.

Experience:
A minimum of five years of clinically related experience in Case Management and Utilization/Concurrent Review is required.

Preferred Qualifications:
Prior supervisory experience is preferred. Familiarity with Milliman Care Guidelines and experience with employer group membership and Medicare/Medicaid benefits contracts is advantageous.

Licenses/Certifications:
Must possess an active RN license in MD, VA, or Washington, DC.
  • Registered Nurse
  • Active State Licensure and/or Compact State Licensure RN

SKILLS AND ABILITIES:
Strong verbal and written communication skills. Comprehensive knowledge of the health benefits industry, products, trends, and competitive landscape. Proficiency in utilizing metrics and measures for program and service management. Excellent organizational skills to handle multiple projects and priorities. Basic understanding of the strategic and financial objectives of a healthcare system or payer organization, including health plan operations.

Knowledge of managed care principles, including HEDIS standards, and case management practices.

Ability to mentor and coach team members to achieve goals, provide objective performance evaluations, and implement strategies for individual and team improvement.


SALARY RANGE:
$77,544 - $159,935. This range is specific to the role and considers various factors such as responsibilities, candidate experience, education, internal equity, and market conditions. CareFirst offers a comprehensive benefits package, incentive programs, and 401k contributions, all subject to eligibility requirements.

EQUAL EMPLOYMENT OPPORTUNITY:
CareFirst BlueCross BlueShield is an Equal Opportunity employer, committed to providing equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

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