Clinical Care Team Manager
- Manages the daily operations of Clinical USSC team, ensuring operation goals and timelines are met. Manages and Coordinates the workload of the Navigators and Clinicians.
- Manages performance and performs quality control audits to guarantee high level of accuracy, cost control and customer service.
- Performs medical necessity evaluations pre and post claim and supports teams’ activities where needed. Is an expert of the US Clinical Care Navigation and Preauthorization / Medical Necessity reviews and approvals.
- Is in continuous contact with US TPA’s and internal departments for a successful outcome. Manages all Care Navigators and US Clinicians in USA and regions
- Works directly with Head of USSC and with BGLA Medical Management / Head of MST, for best practices relating to Clinical Governance, US case related escalations and US complex cases.
- Protects and ensures accuracy, navigation (care / savings / cost efficient centers of excellence) and right decisions regarding complex cases, preauthorization of inpatient services. Ensures the navigators and clinicians are giving our members proper navigation within the US healthcare system and helping members make the appropriate decisions regarding their medical needs.
- Partners with all Bupa’s clinical operations teams (BG, BGLA, etc.) to leverage knowledge, capability, and process compliance as well as with our US Service Partners (GEM, AHA, GEOBLUE), who perform provider case management.
- This role is responsible for the issuance of all preauthorization or precertification based on medical necessity for complex cases.
- The role is responsible of guiding patients and caregivers, helping them navigate through the USA health care system to ensure their healthcare needs are met.
- The role must take ownership of the case and navigate the member, broker or assigned intermediary through the patient’s episode of care, managing members’ expectations following company guidelines. Also manages the whole Navigators and Clinician team is doing the same.
- Responsible for all Bupa Global members accessing care in the US through the BCBS agreement and in the case of Bupa Global Latin-American members, also for the members accessing care through GEM or any other US agreement.
- Owns USSC Preauthorization and US Case Management KPIs, Accuracy and Quality of service. Responsible of USSC inventory management and cases to rest of USSC staff members, for the benefit of quick turnaround times and attention to our members; special focus on emergency and complex preauthorization.
- Revise daily departmental priorities, assigns resources, and create work schedules accordingly. Maintain appropriate staffing level, supervises the daily activities, and prioritizes workload of Clinicians and Navigators so daily/weekly departmental deadlines are met.
- Measures team member’s performance against key performance indicators. Evaluates and performs performance feedback while taking appropriate actions necessary to maintain optimal performance including disciplinary actions as required. Conducts employee performance evaluations for company’s annual/mid-year performance appraisals. Provide management and professional guidance to team members through regular one on one meeting, regular team meetings, and performance goals.
- Implements and carries out the progressive disciplinary process when appropriate as per established guidelines and policies. Enforces all company and departmental policies.
- Manages time and attendance for direct reports. Monitors and reviews report for extra hours worked.
- Trains and motivates new and existing staff for the effective administration of the department and ensures team members are taking proactive actions to resolve deficiencies to ensure the best level of service is being delivered both internally and externally.
- Completes quality control audits that allow review of at least 5% of the activities completed by the team (authorization letter, E-mails, calls, notes quality).
- Ensures cases are solved timely in compliance with policy and company provisions. Manages escalated cases up to resolution working directly with various departments, providers, customers, and agents as necessary. Escalates cases to Head of USSC and Head of MST as needed, as well as to USA Network partners clinical or management staff.
- Ensures claims pending doctor review (PDOC), FYC or other assigned claim reviews are completed timely and with high level of quality.
- Approves the intervention of local auditors to evaluate complex cases.
- Identification, reporting and escalation of potentially fraudulent activity identified at any time of the evaluation process.
- Monitors feedback from Quality Assurance, Customer services and Resolution Team area to enhance team performance and determine areas of improvement or training.
- Ensures patients and caregivers are being navigated through appropriate services in the US. Manages and Facilitates communication between the patient, family members, and healthcare providers to ensure patient satisfaction and quality of care. Sends letter of authorization or denial and explanation of benefits based on policy conditions and or Non-Disclosure Review. Ensures the team is accurate in the process.
- Manages link between patient and clinical staff, administration, physicians, and community/external resources to coordinate/maximize resources and identify/resolve barriers to the plan of care.
- Offers second medical opinion service, following company guidelines. Manages all escalations that must be included in Head of/Director level reviews or heightened to appeals
- Escalates cases to the US network provider, where applicable and owns the resolution of these, when interfering in the experience of care from the patient, member, broker, etc.
- Supports the call center staff to meet customer service Key Performance Indicators.
- Guarantee the compliance with Clinical Governance enterprise policy.
- Flexible to peak seasons and months, with ability to attend to after-hour, weekends, and holiday necessities as related to the Navigator/Clinician team roles. Also, ability to attend shifts that are according to company policy, and that span from hours as indicated by the requirements of the role and team coverage.
The Ideal Candidate
- 8-10 years of clinical experience working in a hospital, managed care environment or medical office required.
- Case Management in US IPMI environment preferred. Case Management certification (or related) a plus
- Bachelor’s degree in healthcare administration or Healthcare management required
- RN certification required.
- Management of clinical staff and customer service experience as it relates to care management required.
- Excellent knowledge of US Medical Management tools & guidelines
- Ability to identify resources and utilize problem solving skills to meet patient's individual needs
- Able to take and follow through with delegated tasks and accountability
- Ability to process and handle confidential information with discretion
- Ability to handle difficult and stressful situations with professional composure and empathy
- Excellent listening and interpersonal skills
- Bilingual (Spanish/English); Business communication (verbal and written) proficiency in English required
- Excellent resource planning, time management and organizational skills
- High understanding and proper handling of EMR
** Please assure to include and upload an updated copy of your Resume to your application/profile **
** Porfavor, Asegúrese de incluir y cargar una copia actualizada de su currículum en su solicitud/perfil. **