This job manages a team of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources. Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective. Manages areas which may include authorizing inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting. Utilizes the applicable medical policy and industry standards, and accurately interprets benefits and managed care products. The incumbent is accountable for the oversight; development and maintenance of the department’s care management processes. This includes utilization management, strategic planning, care cost initiatives, system development and quality outcomes. Hires, trains, coaches, counsels, and evaluates performance of direct reports. The incumbent is responsible for compliance with NCQA, URAC, CMS, DOH, and DOL regulations. Also responsible for appropriate application of medical policy and criteria. Works closely with claims, service, Provider Relations and other departments within the corporation to resolve issues and ensure activities coincide with Utilization Management processes.
- Manage and coordinate all department activities; staff education, policy and procedure development and revision, individual staff audits, oversee overall operations to ensure compliance to standards and referrals to case management and physician advisor area.
- Role model to staff and assist in the day to day activities as needed.
- Provide service support, training and performance statistics to the team in addition to initiating and implementing process improvements.
- Perform management functions including, but not limited to recruitment, selection, orientation, performance measurement; counseling, and performance improvement planning; promotion and termination per corporate policy; and career development and support of staff.
- Apply clinical knowledge to work with facilities and providers for care-coordination. May also manage appeals for services denied.
- Conduct staff meetings that ensure corporate and operational communication supported by meeting minutes; and provide an open forum for issues and problem solving.
- Set appropriate targets, measure outcomes and establish plans to negate variances in quality, staff retention, finance and customer satisfaction.
- Provide direct reports with guidance and educational tools to ensure compliance with NCQA, URAC, DOH, DOL and CMS.
- Review and provide input into the oversight of policies and procedures to support regulatory requirements related to Utilization Review.
- Develop and implement appropriate audit requirements to ensure compliance with all staff activity related to Utilization Review.
- Ensure that all staff achieves the minimal qualification of their position through ongoing staff development, counsel and motivate employees, evaluate employees, investigate complaints or performance concerns; implement disciplinary action as needed and in consultation with appropriate authority and Employee Relations.
- Maintain consistent and open lines of communication with internal and external customers.
- Communicate changes in processes and programs order to enhance a share vision and mission.
- Communicate outcomes, data analysis, complex processes and action plans to division/unit staff, corporate partners, and external customers.
- Facilitate and lead informational and educational meetings for internal and external customers.
- Accountable for special projects and enhanced activities within the department.
- Participate in the development and implementation of department/division projects.
- Implement integration processes and planning activities.
- Other duties as assigned or requested.
- Bachelor’s Degree
- Master’s Degree in Business Administration/Management or related Healthcare field
- 5 – 7 years in a Clinical setting
- 3 – 5 years in Utilization Management or Managed Care
Licenses & Certifications
Current license in one or more of the following disciplines:
- Registered Nurse (RN)
- Licensed Clinical Social Worker (LCSW)
- Licensed Social Worker (LSW)
- Licensed Professional Counselor (LPC)
- Other related Clinical License
How to Apply
Send resume to email@example.com and in email, entitle the subject line with the name of the position and in the body of the email include why you would be good fit for the position.