RN Clinical Health Liaison - BCBSTX

Job ID: PT-1018568 Description:

HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants.We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

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Please note that only requests for accommodations in the application process will be returned. All applications, including resumes, must be submitted through HCSC's Career website on-line application process. If you have general questions regarding the status of an existing application, navigate to "my account" and click on "View your job submissions".

BASIC FUNCTION:

The Registered Nurse (RN) is responsible for the monitoring of Clinical Health and/or medical issues involving Vendors / Medical Group / Individual Physician Associations (IPAs), members, providers, and vendors; assisting medical groups in following the Medical Health guidelines; assisting members in accessing health care; assisting members and medical groups in resolution of complex / unusual quality of care or claim issues; Also responsible for performing on-site audits for clinical service providers for state and federal regulations, and quality purposes; providing one-on-one and group trainings for providers, marketing, staff; and as assigned as nurse liaison for several medical groups, responsible for Clinical Management including Utilization Management (UM) Case Management (CM) Disease Management (DM) Quality Improvement (QI) and coordination of care (CC) management duties, the Clinical Work Plan and Evaluations, case files and annual clinical audits for assigned service vendor, Medical Groups / IPA's. This position is involved in oversight of clinical health vendor agreements including review of adherence to contract requirements and may draft amendments to agreements. Provide oversight and support to HCSC Clinical Operations areas to coordinate consistency between subcontractors and the Health plan operational areas.

JOB REQUIREMENTS:

  • Bachelor's degree in Nursing, Registered Nurse (RN) and an unrestricted license in the state of Operation.
  • 5 years' experience in Clinical health care management.
  • 3 years' managed care experience and health plan operations (Commercial Medicaid and Medicare)
  • Skills/experience to interpret and implement accreditation standards NCQA and URAC.
  • Skills/experience to interpret and implement multiple state and federal health insurance regulations.
  • Organizational skills for implementing new products and groups state wide.
  • Verbal and written communications skills to include delivering presentations to committees on audit results, implementation plans and acting as company representative to subcontractor management (Vendors and Delegates).
  • PC experience to include Microsoft Office suite of applications (Word, Excel)
  • Able and willing to travel, including overnight stays (approximately 30 instances of overnight travel, 40%).

PREFERRED JOB REQUIREMENTS:

  • Bachelor's degree in Health Care Administration, or Health Care field.
  • Presentation application experience (such as PowerPoint) and database experience.
  • Project management experience including leading projects.
  • Demonstrated training experience, development & delivery
  • Implementing medical management systems for clinical or behavioral health
  • Implementing program or policy with workflows
  • Auditing, case files or hospital records.

Located in Richardson, TX.

  • LI CB CA

Requirements: Expertise Nursing Job Type Full-Time Regular Location TX - Richardson


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