Manager, Utilization Management RN - Peak Health

WVU Medicine

97d

About The Position

This role will be responsible for the oversight of a program that is focused on driving the decrease in care variance, to ensure timely discharges, and to refer members to other plan resources to meet their care conditions. Reporting to the Health Plan Director of Medical Management, the Utilization Review Manager will be an integral member of the health plan’s medical management team. The incumbent is a collaborative member of the Medical Management team.

Requirements

• Bachelor of Science in Healthcare or related field.
• Five (5) years of healthcare clinical experience in Utilization Review.

Nice To Haves

• Bachelor of Science in Nursing (BSN).
• Medical Management for Medicare and/or Medicaid populations preferred.
• Utilization Management experience preferred.

Responsibilities

• Oversees the build and implement care management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews) that are consistent with established industry and corporate standards.
• Manages the build and implement all care management reviews according to accepted and established criteria, as well as other clinical guidelines and policies.
• Ensures that interventions are collaborative and focus on maximizing the member’s health care outcomes.
• Supervises the facilitation of the Peer-to-Peer Review process, and work with the Medical Directors to continuously improve member and Provider Network services for this process.
• Oversees the education that is provided to internal and external stakeholders and partners to continuously improve processes and build network relationships.
• Facilitates a collaborative environment that focuses on collaboration with other members of the medical management team to identify members whose healthcare outcomes may be enhanced by coaching and/or case management interventions.
• Educates team members on the data that is collected within the position and facilitate improvement in outcomes within the team.
• When needed, fills in for staff members to ensure that the operations of the medical management team are never compromised.
• Commits to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Management.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees