The Role 
The RN Manager will be leading and overseeing a case management/utilization management team, including but not limited to: operations, executing policies and procedures, and provide associate development and performance management. The RN Manager is responsible for monitoring and achieving group metrics, such as cost and risk and ensuring continuous quality and improvements. 
 
The Team 
 
Key Responsibilities:  

• Implement strategic and operational goals for the CM/UM group; implement and monitor supporting plans 

• Oversee the CM/UM group, providing group communications and issue escalation / resolution support 

• Maintain awareness, attitude, knowledge, and skills to work effectively with a culturally and demographically diverse population 

• Serve as a mentor and advisor to CM and UM’s as they work through complex or particularly unique cases 

• Become an expert of BCBSMA’s products, benefits, healthcare delivery system, accreditation, regulatory requirements, and community resources 

• Interpret, evaluate, and clearly document complex medical information using a directive and focused approach in order to identify relevant and actionable conditions, circumstances, and behaviors 

• Meet deadlines, and deliver expected outcomes with appropriate sense of urgency 

• Build effective relationships internally and externally, in person and virtually, in order to facilitate professional and business goals 

• Effectively negotiate clinical operations environment; Manages clinical and non-clinical resources effectively (e.g., cost, productivity) 

• Maintain knowledge of all clinical areas and specific member population 

• Responsible for staff management and development including, recruiting and rewarding staff, setting performance expectations, and assessing, monitoring, and counseling staff regarding individual performance 

• Articulate performance expectations and establish ongoing training programs for case management associates to achieve these expectations 

• Provide management and direction to ad-hoc projects requested by senior management 

• Track, analyze, interpret, and report regularly to leadership on case management group performance metrics 

• Conduct audits to ensure productivity and performance are meeting or exceeding performance expectations; implement plans to address performance gaps 

• Adherence to program, departmental and organizational performance metrics 

• Foster clinical excellence by promoting and participating in educational opportunities 

Key Qualifications: 

• Managing in a Clinical Operations Environment (manages clinical and collaborates with non-clinical resources effectively; facilitates staff and team engagement in and accomplishment of clinical, business, and service goals in order to achieve organizational objectives) 

• Knowledge of specialized subject matter (demonstrates the use of the right resources and application of the correct policies in order to support clinical determinations and administration of benefit based on product, segment, account, and clinical specialty program needs and objectives) 

• Focus (ability to identify and manage to key, high-leverage information, tasks, and events) 

• Consistency (ability to facilitate staff adherence to identified workflows, plan requirements, clinical guidelines, to drive sound, objective decisions) 

• Negotiation (ability to resolve disputes and craft outcomes that address competing interests while achieving business objectives) 

• Call management (ability to structure staff workflows that drive telephone conversations that ensure value in every contact, achieve the desired objectives for placing the call, and are efficient and professional) 

• Clinical Management (ability to design workflows, identify processes, and facilitate consultative discussions that enable team members to conduct clinical assessment, clinical review, and management of an end to end episode of care) 

• Productivity (ability to prioritize and manage assigned workload to accomplish full slate of targeted activities) 

• Comfort and proficiency with the use of computers and technology (ability to navigate computer applications quickly and effectively, key in data proficiently in real time during phone calls, work effectively with the phone system, and quickly learn, and effectively work in, a variety of media) 

Education and Experience: 

• Active licensure in Massachusetts is required, appropriate to position (RN, PT, CCM, LICSW, LMHC, BCBA) Licensure in additional states a plus; any restrictions against a license must be disclosed and reviewed. 

• For Registered Nurses Only: A Bachelor’s degree in nursing (BSN) is required; Master’s degree, preferred. 

• Minimum 3-5 years of RN supervisory and/or management experience, desirable 

• Knowledge in the case management/utilization management process, programs, services, business implications, trends, and policies 

• Critical thinking & problem-solving skills 

• Adaptability, flexibility, and self-discipline 

• Exceptional communication, writing, presentation, and negotiation skills 

• Proficiency with Information Technology systems 

• Bilingual, a plus