Manager – Pre Service Medical Review
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Job Description
Florida Blue manager overseeing clinical and non-clinical pre-service medical review. Leading authorization operations, regulatory compliance, team performance, and continuous quality improvement.
Responsibilities:
- Administer clinical and non-clinical referral authorization and voluntary pre-service review for all lines of business
- Resolve clinical and non-clinical inquiries to enhance member and provider experience
- Ensure compliance with regulatory and legislative mandates and operational objectives through standardized processes
- Coach Pre-Service Medical Review members toward becoming a high-performing team
- Identify, implement, and monitor continuous quality improvement initiatives
- Manage clinical and non-clinical capabilities using BCBSF management processes
- Monitor operational performance, budgeting, staffing, resource management, and performance objectives using Centre-Vue, Siebel, Quest, and related systems
- Lead team members to meet individual, team, and operational goals involving telephone, fax, held authorizations, and inventories
- Provide guidance on clinical and non-clinical standards and manage regional department operations
- Coordinate and resolve issues and facilitate career and succession planning
- Ensure adherence to NCQA, HCFA, DOI, and AHCA requirements and internal policies and procedures
- Manage internal and external boundaries, monitor service level agreements, and identify the need for new agreements
Requirements:
- 5+ years related work experience in managed care
- 2+ years direct supervisory/management experience
- Related Bachelor’s degree or additional related equivalent work experience
- Occasional travel required, including 10% travel within the State of Florida
- Leadership skills, including communicating, inspiring, empowering, and resolving conflicts
- Knowledge of general management practices, including organizing, planning, controlling, budget/expenditure control, and HR programs/practices
- Excellent written and verbal communication skills with ability to communicate effectively at all organizational levels and with diverse audiences
- Proven ability to build relationships within the business area, across the organization, and externally to BCBSF
- Proven ability to resolve issues and barriers
- Knowledge of continuous improvement processes, including Six Sigma or other TQM methodologies and tools
- Knowledge of healthcare regulatory requirements
- Customer service knowledge
- Knowledge of Microsoft Office, including Outlook
Benefits:
- Medical, dental, vision, life and global travel health insurance
- Short- and long-term disability programs
- Leave programs to support personal circumstances
- Retirement Savings Plan including employer match
- Paid time off
- Volunteer time off
- 10 holidays and 2 well-being days
- Additional voluntary benefits
- Comprehensive wellness program
- Opportunities for incentive or commission compensation
- Regular annual reviews with pay for performance considerations for base pay increases
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