Manager – Pre Service Medical Review

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🔥 7 minutes ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $84.5k - $105.6k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

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GuideWell Source

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

💼 Consulting

⚕️ Healthcare Insurance

Healthcare • Consulting • Healthcare Insurance

GuideWell Source is a company within the GuideWell Family that focuses on accelerating innovative health solutions to market, transforming and reshaping the health industry. It specializes in healthcare delivery, providing new models and superior outcomes for patients. The company emphasizes consumerism in healthcare, engaging clients in meaningful ways. GuideWell Source offers healthcare insurance, protecting employers and consumers with coverage plans and services. The company also provides administrative and claims processing services for state and federal Medicare and Medicaid programs, establishing itself as a trusted business partner in the healthcare sector with a focus on operational excellence.

📋 Description

• Administer clinical and non-clinical referral authorization and voluntary pre-service review for all lines of business • Resolve clinical and non-clinical inquiries to enhance member and provider experience • Ensure compliance with regulatory and legislative mandates and operational objectives through standardized processes • Coach Pre-Service Medical Review members toward becoming a high-performing team • Identify, implement, and monitor continuous quality improvement initiatives • Manage clinical and non-clinical capabilities using BCBSF management processes • Monitor operational performance, budgeting, staffing, resource management, and performance objectives using Centre-Vue, Siebel, Quest, and related systems • Lead team members to meet individual, team, and operational goals involving telephone, fax, held authorizations, and inventories • Provide guidance on clinical and non-clinical standards and manage regional department operations • Coordinate and resolve issues and facilitate career and succession planning • Ensure adherence to NCQA, HCFA, DOI, and AHCA requirements and internal policies and procedures • Manage internal and external boundaries, monitor service level agreements, and identify the need for new agreements

🎯 Requirements

• 5+ years related work experience in managed care • 2+ years direct supervisory/management experience • Related Bachelor’s degree or additional related equivalent work experience • Occasional travel required, including 10% travel within the State of Florida • Leadership skills, including communicating, inspiring, empowering, and resolving conflicts • Knowledge of general management practices, including organizing, planning, controlling, budget/expenditure control, and HR programs/practices • Excellent written and verbal communication skills with ability to communicate effectively at all organizational levels and with diverse audiences • Proven ability to build relationships within the business area, across the organization, and externally to BCBSF • Proven ability to resolve issues and barriers • Knowledge of continuous improvement processes, including Six Sigma or other TQM methodologies and tools • Knowledge of healthcare regulatory requirements • Customer service knowledge • Knowledge of Microsoft Office, including Outlook

🏖️ Benefits

• Medical, dental, vision, life and global travel health insurance • Short- and long-term disability programs • Leave programs to support personal circumstances • Retirement Savings Plan including employer match • Paid time off • Volunteer time off • 10 holidays and 2 well-being days • Additional voluntary benefits • Comprehensive wellness program • Opportunities for incentive or commission compensation • Regular annual reviews with pay for performance considerations for base pay increases