[Remote] Mgr, RN Clinical Ops

Note: The job is a remote job and is open to candidates in USA. Horizon 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. 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. Skills • 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. • Prefers professional certification in a clinical specialty as appropriate to the business unit. • Prefer knowledge of Plan products, applications, policies, procedures and systems. Education Requirements • High School Diploma/GED required. • Bachelor degree in Nursing or health related field preferred or relevant experience in lieu of degree. Benefits • Comprehensive health benefits (Medical/Dental/Vision) • Retirement Plans • Generous PTO • Incentive Plans • Wellness Programs • Paid Volunteer Time Off • Tuition Reimbursement Company Overview • Horizon Blue Cross Blue Shield of New Jersey is a company that provides health insurance products. It was founded in 1932, and is headquartered in Newark, New Jersey, USA, with a workforce of 5001-10000 employees. Its website is Company H1B Sponsorship • Horizon Blue Cross Blue Shield of New Jersey has a track record of offering H1B sponsorships, with 6 in 2025, 7 in 2024, 6 in 2023, 1 in 2021. Please note that this does not guarantee sponsorship for this specific role. Apply tot his job