Manager, Utilization Management
About The Position
Manager, Utilization Management Who We Are: TurningPoint Healthcare Solutions is a leader in advanced clinical and technology-enabled complex condition management. TurningPoint provides an innovative suite of specialty care management services and technologies that enable health plans and employers to improve the safety, quality, and affordability of healthcare. Through its platform and specialized team of clinical experts, TurningPoint works collaboratively with providers to deliver optimal care. TurningPoint offers condition-specific, quality-driven, value-based care management services that optimize care from diagnosis and discovery through recovery. TurningPoint’s comprehensive and integrated suite of services enhances the support individuals need, at the time they need it most. Since launching in 2015, TurningPoint has provided support to more than 50 million people nationwide across numerous clinical specialties including musculoskeletal, pain management, cardiology, wound care, ear/nose/throat, and sleep. TurningPoint’s model moves beyond denial-based care to holistic condition management that improves outcomes and reduces cost. TurningPoint is an independent organization, not owned or affiliated with a health plan or provider system. Position Summary: The Manager of Utilization Management leads and manages the utilization review staff of CRN supervisors and programs while promoting the success of Utilization Management functions through clinical review and application of policies and procedures that incorporate best practices.
Requirements
- Bachelor’s Degree in Nursing (BSN), Health Administration, Business related field and/or equivalent experience
- Active and unrestricted license to practice must be maintained.
- Licensed Registered Nurse (RN) is strongly preferred
- Five years’ management experience in a managed health care setting
- Five years’ experience in medical industry
- Strong communication and management skills
- Advanced demonstrated problem-solving skills; independent problem solving to overcome barriers and meet deadlines
- Advanced ability to work within tight timeframes and meet strict deadlines
- Requires strong presentation skills to be utilized throughout all levels of the organization
- Must be able to foster a positive and productive work environment with the ability to lead, build teams and motivate staff
- Intermediate proficiency in Microsoft Office Suite (Excel, Outlook, PowerPoint, Word)
- Previous experience in Utilization Management/Managed Care environment
Responsibilities
- Accountable for managing in an efficient manner the utilization and prior authorization management activities designed to achieve quality and service-driven objects
- Oversees all phases of development, organization, planning and implementation of projects/initiatives/work flows/processes to enhance quality-driven outcomes
- Maintains and improves productivity and operations by monitoring system performance; identifying and resolving problems; preparing and completing action plans; participating in system audits and analyses
- Works collaboratively with the medical directors, peer reviewers and nurses to ensure consistency in review process
- Possess the flexibility to act as a subject matter expert liaison and/or leader on cross-functional teams
- Assists in designing, planning, and implementing clinical projects and new programs/services
- Accomplishes Human Resources objectives by selecting, orienting, training, assigning, coaching, counseling qualified staff; communicating job expectations; monitoring and reviewing job performance; planning and reviewing compensation action
- Prepares performance reports by collecting, analyzing, and summarizing data and trends
- Serves as an initial clinical reviewer, as needed.
- Performs clinical reviews and provides documented recommendations based on the use of appropriate clinical guidelines and applicable client, state, and federal regulations and guidelines
- Meets medical operational standards by contributing information to plans and reviews; implementing production, productivity, quality and customer-service standards; resolving problems; identifying system improvements
- Supports non-clinical staff with clinically related questions or issues that arise within the scope of practice
- Attends and participates in Management, Utilization Management Committee (UMC) and Quality Management Committee (QMC) meetings, as necessary
- Participates in quality improvement projects execution, monitoring and reporting
- Serves and protects the company by adhering to all: NCQA and URAC standards; company policies and procedures; federal, state, and local requirements; and professional and licensing standards
- Respects and maintains HIPAA, PHI and company confidentiality guidelines
- Other duties as directed
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What This Job Offers
Job Type
Full-time
Career Level
Manager
