Manager – Pre Service Medical Review

This is a fully remote position, open to applicants in Florida.

📋 Description

• Oversee both clinical and non-clinical referral authorization as well as voluntary pre-service review across all business lines.

• Address clinical and non-clinical inquiries to improve the experience for members and providers.

• Ensure adherence to regulatory and legislative requirements as well as operational goals through standardized procedures.

• Mentor Pre-Service Medical Review team members to cultivate a high-performing group.

• Identify, execute, and track continuous quality improvement initiatives.

• Administer clinical and non-clinical capabilities in alignment with BCBSF management protocols.

• Evaluate operational performance, budgeting, staffing, resource management, and performance objectives using systems such as Centre-Vue, Siebel, Quest, and others.

• Guide team members to achieve personal, team, and operational objectives involving telephone, fax, held authorizations, and inventory management.

• Provide direction on clinical and non-clinical standards while managing regional department operations.

• Coordinate and troubleshoot issues while facilitating career development and succession planning.

• Ensure compliance with NCQA, HCFA, DOI, and AHCA standards as well as internal policies and procedures.

• Manage internal and external boundaries, oversee service level agreements, and identify the necessity for new agreements.

⛳️ Requirements

• Minimum of 5 years of relevant experience in managed care.

• At least 2 years of direct supervisory or management experience.

• A related Bachelor’s degree or equivalent relevant work experience.

• Occasional travel is necessary, including 10% travel within the State of Florida.

• Leadership capabilities, including effective communication, inspiration, empowerment, and conflict resolution.

• Familiarity with general management practices, including organizing, planning, control, budget/expenditure oversight, and HR programs/practices.

• Exceptional written and verbal communication skills with the ability to engage effectively across all organizational levels and diverse groups.

• Proven ability to foster relationships within the business area, throughout the organization, and externally with BCBSF.

• Demonstrated capability to resolve issues and obstacles.

• Understanding of continuous improvement methodologies, including Six Sigma or other Total Quality Management (TQM) tools.

• Knowledge of healthcare regulatory standards.

• Customer service expertise.

• Proficiency in Microsoft Office applications, including Outlook.

🏝️ Benefits

• Medical, dental, vision, life, and global travel health insurance.

• Short- and long-term disability programs.

• Leave programs designed to accommodate personal circumstances.

• Retirement Savings Plan with employer matching.

• Paid time off.

• Volunteer time off.

• 10 holidays and 2 well-being days.

• Additional voluntary benefits.

• Comprehensive wellness program.

• Opportunities for incentive or commission-based compensation.

• Regular annual performance reviews with pay for performance considerations for base salary increases.