The Volunteer State Health Plan Inc (VSHP) CHOICES program offers person-centered care planning, care coordination, and support services for members receiving long term care and home and community based services. This position is accountable for assisting the leading and planning, administration and coordination of all operational aspects of Home and Community Based Services and Nursing Facility services so that high quality and timely Care Coordination occurs. The CHOICES Manager, Clinical Operations works closely with the Manager, Clinical Ops and Support. This position will be located in Nashville.
Job Duties & Responsibilities
• Manages overall program, staffing, and resources between cross functional clinical and non-clinical staff according to CHOICES enrollment changes. Collaborates on internal policy and procedure development, implementation and revisions to meet state and regulatory compliance standards relating to care coordination services, utilization management, continuum of care, and transitional/discharge planning initiatives
• Acts as subject matter expert for technical assistance to cross-functional team e.g. claims, member services, medical cm, etc.
• Collaborate with and develop effective relationships with the various state agencies (Bureau of TennCare, DCS, Health Departments, Community Service Agencies, DHS, state and federal courts, etc.) to support member needs and advance the image of VSHP
• Ensure cross training of staff with regard to multiple systems, products, networks, benefits designs, and State and Federal Regulations
• Working knowledge of internal and external guidelines as well as applicable federal and state mandated statutes (CMS, NAIC, TDCI, BCA, COBRA, including Title VI guidelines, etc.)
• Maintain working technical support and knowledge of LTC and HCBS current industry practices
• Assist in the development of operational CHOICES enterprise workflows
• Continuously improve job knowledge as it relates to LTC /HCBS benefits claims system, member services claims, performance management tools, products accounts, systems, networks, and compliance to state and federal regulations
• Maintain effective working relationships with internal and external business partners, working closely with those partners as necessary to achieve desired results (Marketing, Legal, claims, member services, UM/CM/DM).
• Manage inquiry escalation or dispute functions as applicable (grievances, appeals, special CHOICES requirements, bureau inquiries etc.)
• Operate in a rapidly changing healthcare environment
• 40-60% travel
• Registered nurse with an active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Act required.
• Minimum 3 years proven, increasing management responsibilities and success in managing the health care environment
• Minimum of 5 years experience in clinical operations (Public health, social welfare, community based mental health services, home health experience should be counted toward the years experience in clinical operations), or quality improvement/assurance, or highly technical process improvements, and/or business process engineering required.
• Minimum 3 years experience providing care coordination to persons receiving long-term care services and an additional 2 years work experience in managed and/or long-term care required.
• Experience in long-term care environment preferred
• Extensive knowledge of the BlueCare and TennCare Select Contractor Risk Agreements, specifically the CHOICES subsection, as well as policies and procedures is preferred.
• Proven ability to conduct root cause analysis, plan, organize and coordinate multiple projects
• Strong interpersonal skills
• Strong analytical and decision making abilities
• Proven ability to speak in public and conduct effective presentations
• Valid Drivers License
• 40-60 % travel required
• Employee may be required to participate in Runzheimer Program (auto reimbursement program)
To apply for this position, please visit our website at https://www.bcbst.com/about/careers/openings/. BlueCross BlueShield of Tennessee is an Affirmative Action and Equal Opportunity Employer.