Horizon Blue Cross Blue Shield of New Jersey · 3 months ago
Mgr, RN Clinical Ops
United States
Full-time
Remote
Mid, Senior Level
$108K/yr - $147K/yr
5+ years expHorizon Blue Cross Blue Shield of New Jersey empowers members to achieve their best health and has been a leader in health solutions for over 90 years. The Mgr, RN Clinical Ops is responsible for providing leadership and oversight of clinical and non-clinical operations, ensuring adherence to regulatory requirements and improving healthcare quality.
Health Care
Responsibilities
Manages, analyzes and coordinates the daily activities of the unit to ensure departmental goals are met with regards to timeliness, accuracy and consistency of medical decisions
Manages and directs staff to ensure overall client satisfaction, appropriate level of service delivery, quality outcomes
Recognizes and identifies opportunities to improve the quality of Care/services and initiates steps and activities to advance outcomes
Subject matter expert for multiple blue list projects, mandate office projects, task forces/Regulatory Committees
Develops and implements policies, procedures, and ad hoc reports to meet regulatory guidelines
Maintains and monitors the departmental budget to ensure administrative costs are managed
Subject matter lead for IPRO, CMS, Burchfield, NCQA audits
Identifies and implements business process improvements to identify efficiencies and cost savings opportunities
Interfaces with other teams and plan areas to assure consistent application of policies and procedures and to facilitate inter-unit/department projects
Represents the Plan with CBU with external group customers and Regulatory affairs for external agencies
Represents the unit on corporate issues and/or in the event of Director's absence
Creates and champions an atmosphere within the team, which fosters open communication, increase employee engagement, teamwork, ownership, and a collaborative cross-departmental environment to implement, optimize and share continuous improvement processes
Determines departmental budget and conducts ongoing expense management
Manages, directs, and develops staff by providing feedback and coaching. Administers performance and salary reviews for staff. Ensures staff meets all regulatory requirements and comprehends and complies with best practice methodology, professional standards, and internal policies and procedures
Qualification
Required
High School Diploma/GED required
Requires minimum of five (5) years' experience in a healthcare-related field
Requires minimum of five (5) years broad clinical experience
Requires minimum of three (3) years direct supervisory experience or demonstrated supervisory experience leading teams in a matrix management environment
Active Unrestricted NJ LCSW, LSW, LMFT, LPC, or RN License required
Requires strong knowledge of functional tasks performed within department
Requires knowledge in the principles of risk management and quality assurance
Requires knowledge of NCQA standards
Requires knowledge of State Mandates and Regulations
Requires knowledge of regulatory bodies and their processes
Requires excellent organizational skills and ability to set priorities
Requires excellent oral and written communication skills
Requires excellent presentation skills
Requires comprehensive leadership and decision-making skills
Requires strong analytical, problem solving, and critical analysis skills to report findings in a complete, succinct and accurate manner
Must be proficient in the use of personal computers and supporting software in a Windows based environment including MS Office products (Word, Excel, PowerPoint) and Outlook; should be knowledgeable in the use of intranet and internet applications
Preferred
Bachelor degree in Nursing or health related field preferred or relevant experience in lieu of degree
Prefers professional certification in a clinical specialty as appropriate to the business unit
Prefer knowledge of Plan products, applications, policies, procedures and systems
Benefits
Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement
Company
Horizon Blue Cross Blue Shield of New Jersey
Horizon Blue Cross Blue Shield of New Jersey is a company that provides health insurance products.
5001-10000 employees
H1B Sponsorship
Horizon Blue Cross Blue Shield of New Jersey has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (7)
2024 (7)
2023 (6)
2021 (1)
Funding
Current Stage
Late StageLeadership Team
Gary St. Hilaire
President & Chief Executive Officer
Recent News
2026-01-06
2025-12-29
2025-12-25
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