Clinical Team Lead

Position Description

The Clinical Team Lead oversees the daily operation of the assigned unit, including but not limited to: providing support of the staff, both office and home based, of their daily activities, assessment and adjustment of assignment based on unit needs, adherence to established policies and desktop procedures, audits for accreditation and regulatory compliance and departmental performance metrics, evaluation of productivity and program performance reports, facilitation of ongoing staff development, and general departmental oversight activities.

Responsibilities and Qualifications

Duties and Responsibilities:

• Acts as preceptor and mentor to the staff by providing regular feedback regarding their performance, through evaluation and counseling following Capital BlueCross Human Resource procedures.

• Acts as liaison with key personnel within the organization and with hospitals, ancillary providers, employer groups and members.

• Identify strengths or weaknesses within assigned unit, including but not limited to trends, outcomes, staff productivity, and other department/organizational goals as established.

• Leads review meetings to facilitate multidisciplinary communication.

• Establishes, manages and evaluates departmental policies, desktop procedures, goals, staffing levels and caseloads, and makes appropriate changes as needed to achieve optimal outcomes.

• Promotes the value of Clinical Programs within the organization and within the provider community.

• Monitors and evaluates staff compliance with established policies and desktop procedures and develops action plans as needed.

• Keep abreast of developing trends, knowledge and skills.

• Assesses and analyzes current process and makes recommendations to manager.

• Assists with the oversight of compliance with regulatory and accreditation standards.

• Assists the manager in planning and development of the concurrent review program.

• Participates in special projects as needed.

• Provides support to staff with ongoing activities.

• Attends and participates in company and departmental meetings and training sessions as required.

Education and Certifications:

• *This position requires a current Pennsylvania RN License; a bachelor's degree is preferred.

• *The incumbent must possess five (5) years of clinical nursing background as an RN in a hospital/alternative care setting.

• *Minimum of two (2) to three (3) years of managed care experience, specifically in utilization management or case management.

• Within 3 years must obtain Certified Case Management (CMM) designation or Certified Case Management Administrator designation.

• *Supervisory experience in a healthcare related field is preferred.

• *Excellent written, oral communication and organization skills.

• *Ability to operate a personal computer (PC), including proficiency in Microsoft Word, Access and Excel.

• *Knowledge of regulatory requirements for Utilization Management including URAC, NCQA, Act 68, ERISA and CMS.

• *Knowledge of current and emerging medical treatment modalities with the ability to analyze and interpret medical and benefit coverage interrelationships.

• Knowledge of all Capital BlueCross products including coverage policies, interacting relationships and claims processing issues.

• *Demonstrates tact and diplomacy when communicating with member, physician(s), and other members of the health care team.

• *Must have reliable form of transportation proof of insurance and a valid Pennsylvania driver's license.

• Knowledge of managed care principles and emerging health treatment modalities.

• *Strong team skills with the ability to work and interact with management level staff both within and outside of Clinical Management.

• *Self motivated and works independently.

• *Anticipates and identifies problems, thoroughly analyzes available information and makes timely, practical decisions exercising good judgment.

Physical Demands:

Some physical exertion involving walking from car and from unit to unit in assigned facilities. Exposure to environmental elements when traveling to and from assigned facilities. Some sedentary work involving periods of sitting, talking, hearing, keying and performing repetitive motions. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor.

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you'll help us live our mission of improving the health and well-being of our members and the communities in which they live.