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Partners with various stakeholders to resolve complex plan issues utilizing available resources and content expertise in support of division budget and objectives. Develop Plan communication strategies to assure care management interventions are consistent with benefit administration and interpretation; participate on internal and external organization's advisory groups; provide oversight of benefit cost initiatives through cross-functional departmental/divisional teams. Assists Plans with using methodologies and strategies to support achievement and maintain high levels of FEP performance.
Maintains knowledge and expertise on current and emerging healthcare issues (particularly HEDIS, accreditation, Population Health/case, and disease management) Provides direction and guidance on operational policy and identification of critical priorities.
Provide guidance in the financial aspects of the Local Plan's financial budgets in relation to DM/CM programs run locally by the Plan or the Plan Vendor.
Translates trend information into strategic action plans resulting in value-added resources that address Plan business needs. May lead, participate, and partnering projects from planning to implementation.
Provide strategic follow-up and clinical recommendations post on-site plan visits and meetings. Provides support to Quality Teams regarding the HEDIS, CAHPS and accreditation initiative.
Acts as a liaison, resource, and partner with Plans, internal BCBSA staff and other external partners., Provides guidance on FEP Program interpretation. Ensures development and/or implementation of required strategies, programs, and benefits. Leverages input/feedback for developing new strategies, programs, and benefits from internal and external partners.
Education
Bachelors Degree
Nursing
Certifications
Certified Diabetic Educator or Certified Health Educator
Certification in case management (CCM)
Academy of Healthcare Management
Active Registered Nursing
Experience
Related managed care and business experience which demonstrates knowledge and understanding of PPO operations and care management.
Skills
Professional nurse
Health administration or public health degree
Related managed care and business experience which demonstrates knowledge and understanding of PPO operations and care management.
Advanced project management skills for planning and executing multiple projects and a detail orientation to ensure compliance with accreditation standards and accuracy of statistics are essential.
Ability to create strategies that support initiatives and translate these into action plans.
Ability to budget and prepare cost projections.
Advanced leadership skills with the ability to delegate and motivate others.
Ability to handle multiple projects, working under pressure and meeting deadlines.
Advanced presentations skills with the ability to plan, facilitate and present at meetings, conferences, etc.
Ability to prioritize and identify critical issues.
Ability to work independently, as a team member, and as a team leader.
Advanced analytical skills with the ability to analyze and interpret data and conduct advanced analysis.
Ability to interact effectively with senior management, both internal/external to the Association.
Excellent interpersonal and communication skills, both written and oral.
Advanced process management skills, with demonstrated customer focus.
Advanced conflict management skills.
Ability to translate complex, technical and/or quantitative information in a clear, concise and understandable manger.
Advanced time and resource management and problem-solving skills.
Ability to collaborate with multiple levels of stakeholders.
Ability to provide interactive information at a professional speaker/consultative level.
Proficiency with the use of a variety of software applications (e.g., Microsoft Word, Excel, and PowerPoint). Familiarity with the access, navigation, search and extradition of information via the Internet.
People Management
No
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Blue Cross Blue Shield Association is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, national origin, age, gender identity, disability, veteran status, genetic information or any other legally protected characteristics.