Clinical Team Lead - Preauthorization

Position Description

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

The Clinical Team Lead oversees the daily operation of the assigned unit, including but not limited to: providing support of the staff, both office and home based, of their daily activities, assessment and adjustment of assignment based on unit needs, adherence to established policies and desktop procedures, audits for accreditation and regulatory compliance and departmental performance metrics, evaluation of productivity and program performance reports, facilitation of ongoing staff development, and general departmental oversight activities.

Responsibilities And Qualifications

• Acts as preceptor and mentor to the staff by providing regular feedback regarding their performance, through evaluation and counseling following Capital BlueCross Human Resource procedures.
• Acts as liaison with key personnel within the organization and with hospitals, ancillary providers, employer groups and members.
• Identify strengths or weaknesses within assigned unit, including but not limited to trends, outcomes, staff productivity, and other department/organizational goals as established.
• Leads review meetings to facilitate multidisciplinary communication.
• Establishes, manages and evaluates departmental policies, desktop procedures, goals, staffing levels and caseloads, and makes appropriate changes as needed to achieve optimal outcomes.
• Promotes the value of Clinical Programs within the organization and within the provider community.
• Monitors and evaluates staff compliance with established policies and desktop procedures and develops action plans as needed.
• Keep abreast of developing trends, knowledge and skills.
• Assesses and analyzes current process and makes recommendations to manager.
• Assists with the oversight of compliance with regulatory and accreditation standards.
• Assists the manager in planning and development of the concurrent review program.
• Participates in special projects as needed.
• Provides support to staff with ongoing activities.
• Attends and participates in company and departmental meetings and training sessions as required.
  
  

Skills

• Excellent written, oral communication and organization skills.
• Ability to operate a personal computer (PC), including proficiency in Microsoft Word, Access and Excel.
• Demonstrates tact and diplomacy when communicating with member, physician(s), and other members of the health care team.
• Must have reliable form of transportation proof of insurance and a valid Pennsylvania driver’s license.
• Strong team skills with the ability to work and interact with management level staff both within and outside of Clinical Management.
• Self motivated and works independently.
• Anticipates and identifies problems, thoroughly analyzes available information and makes timely, practical decisions exercising good judgment.
  
  

Knowledge

• Knowledge of regulatory requirements for Utilization Management including URAC, NCQA, Act 68, ERISA and CMS.
• Knowledge of current and emerging medical treatment modalities with the ability to analyze and interpret medical and benefit coverage interrelationships.
• Knowledge of all Capital BlueCross products including coverage policies, interacting relationships and claims processing issues.
• Knowledge of managed care principles and emerging health treatment modalities.
  
  

Experience

• Minimum five years of experience in a managed care/health insurance Utilization management, as well as 3 years clinical experience working in an acute care hospital, post-acute care facility, residential treatment center, etc. required
• Previous supervisory experience preferred.
  
  

Education And Certifications

• If applying for a clinical team lead to support the Concurrent Review and/or Behavioral Health function the following is required:
• Must have active current and unrestricted master’s level Behavioral Health clinical license in the state of Pennsylvania (LMSW, LCSW, LISW, LPC, or comparable) or Registered Nurse licensure in Pennsylvania.
• Case Management Certification preferred. Subsequent to completing one (1) year in the position, the incumbent must obtain national certification as a case manager.
• If applying for a clinical team lead to support the Prior Authorization and/or Medical Claim Review function the following is required:
• Must have active and unrestricted Registered Nurse or Licensed Practical Nurse license in Pennsylvania
  

Physical Demands

Some physical exertion involving walking from car and from unit to unit in assigned facilities. Exposure to environmental elements when traveling to and from assigned facilities. Some sedentary work involving periods of sitting, talking, hearing, keying and performing repetitive motions. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor.

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.

And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.

Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association. We are an equal opportunity/affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.