This position will be responsible for growth and development of the clinical operations that surround behavioral health. The incumbent will provide leadership in developing processes and procedures that will build effective working relationships within the company as well as with our behavioral health vendor. This position will be the liaison for departmental functions that cross over to our behavioral health vendor.

ESSENTIAL DUTIES & RESPONSIBILITIES

• Works cross-departmentally to create, strengthen and integrate CBC’s clinical core in Behavioral Health (BH) program.


• Creates policies and procedures to align with CBC’s clinical vision for Behavioral Health.


• Assists the Delegated Oversight resource with NCQA standards by presenting data and documentation needed to maintain accreditation


• Performs an annual audit of the behavioral health vendor that will comply with NCQA, State, Federal and CMS regulations


• Creates internal data reports and reviews monthly, quarterly and annual reports from the behavioral health vendor which will lead to quality improvement strategies


• Facilitates and lead meetings which will integrate and strengthen the relationship between various departments at Capital and the behavioral health vendor


• Delegates tasks throughout the department to ensure compliance is maintained


• Teaches and Trains as needed


• Demonstrates impeccable organizational skills


• Stay abreast of the state and federal regulations for behavioral health, tracks industry trends, and reviews BCBSA impacts


• Coordinates with operations team to streamline process for the COC, Provider Manual, and Claim Codes for behavioral health.


• Participates in cross departmental meetings as defined by the new vendor management structure.


• Addresses member, provider, and internal complaints.


• Develops clinical cost savings initiatives directly related to Behavioral Health.


• Reviews current clinical BH programs against what is available from vendor to evaluate programs for CBC.


• Creates a monthly behavioral health clinical report for CMO.


• Assists in aligning the COC, Provider Manual and Claim Codes

JOB REQUIREMENTS

​Experience:

• RN/LPN or 3-5  years’ relative experience

Education/Licenses/Certifications:

• Certified Professional Coder


• Prefer RN/LPN

Skills:

• Ability to foresee and analyze issues


• Analyze solutions determined by impact & document resolution


• Ability to develop & revised processes and procedures


• Ability to work cross-functionally


• Analytical and report writing skills


• Experience with MS Office Suite & other peripheral systems (i.e., Facets)


• Ability to effectively communicate in both writing and verbal skills


• Ability to work independently or in a team setting


• Exceptional critical thinking skills

Knowledge:

• Strong understanding of NCQA, State and Federal regulations (Acts 68, 62 and 106)


• Stays abreast of the state and Federal regulations that pertain to behavioral health, tracks industry trends, and reviews BCBSA impacts

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.


• The employee must be able to work over 40 hours per week.


• The employee must occasionally lift and/or move up to 5 pounds.

Capital BlueCross is an independent licensee of the BlueCross BlueShield Association. We are an equal opportunity/affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.