We are seeking a dynamic leader to oversee a dedicated clinical care team, ensuring exceptional service delivery and efficient management of medical claims costs. In this role, you will actively lead day-to-day operations, ensuring compliance with policies, contractual obligations, and regulatory guidelines. Serving as a medical resource, you will support members, providers, and non-clinical staff.
Responsibilities
Manage, analyze, and coordinate daily activities to meet departmental goals in quality, timeliness, accuracy, and consistency of medical decisions.
Ensure team compliance with regulatory requirements and adherence to best practices, internal policies, and procedures.
Continuously evaluate workflows, driving process improvements within the department.
Coordinate data collection, review compliance reports, and identify opportunities for operational enhancements and cost efficiencies.
Act as a key liaison between Medical Directors, Management leadership, and staff, representing the department in internal committees and special projects.
Develop key performance indicators to evaluate service levels for both internal and external stakeholders.
Serve as a subject matter expert for complex matters, representing the organization externally with customers, providers, and agencies.
Support Manager in coordinating regulatory, quality, and accreditation activities.
Foster a collaborative team environment that encourages open communication, teamwork, and continuous improvement processes.
Provide feedback, coaching, and development opportunities to staff, ensuring performance goals are met and regulatory standards are upheld.
Assist in budget preparation and monitoring to achieve administrative cost objectives.
Education/Experience
Nursing degree or Masters in a Behavioral health related field, or Bachelors in a health-related field required.
Minimum of two years' full-time acute healthcare/direct clinical care experience.
Minimum of one year direct supervisory experience or demonstrated leadership in a matrix management environment preferred.
Certification as a case manager and three years' experience in case management preferred.
Minimum of 12 months experience in a managed care setting or health insurance industry required.
Additional Requirements
Active Unrestricted NJ LCSW, LMFT, LPC, or RN/PT License required.
Medicaid Case Management: Active Unrestricted NJ LSW, LCSW, LMFT, LPC, or RN/PT License required.
Knowledge, Skills, And Abilities
Strong knowledge of Utilization Management (UM) and managed care principles.
Familiarity with Case Management/Disease Management Standards of Practice.
Understanding of health care systems, medical documentation, state mandates, regulations, and NCQA accreditation standards.
Excellent communication skills, both verbal and written.
Proficiency in MS Office (Word, Excel, PowerPoint), Outlook, and internet applications.
Strong analytical thinking and organizational skills.
Travel
Travel required to other offices, provider locations, and/or for oversight of remotely located workforce members as needed.
Salary Range
$84,700 - $115,605 per year, commensurate with experience and qualifications.
Benefits
Comprehensive health benefits (Medical/Dental/Vision).
Retirement Plans.
Generous PTO.
Incentive Plans.
Wellness Programs.
Paid Volunteer Time Off.
Tuition Reimbursement.
Employment Type: Full-Time
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Health Care Provider
Industries
Human Resources Services
Referrals increase your chances of interviewing at Get It Recruit - Healthcare by 2x