Manager, Utilization Management
About The Position
The Manager, Utilization Management oversees utilization management activities to ensure consistent services and achievement of utilization targets. The role coordinates and manages the pre-determination process for medical and dental services, supports consistent application of authorization criteria, and helps ensure decisions to deny or reduce services are made by appropriately qualified health care professionals. The Manager develops and oversees integrated service delivery, utilization management data and processes, regulatory compliance, reporting, workflows, productivity, utilization trends, audits, and continuous quality improvement activities. The position works with providers, staff, and other departments to align benefits and practices with state regulations, NCQA and/or URAC requirements, and CareSource policies; analyzes utilization trends and their effects on member care and outcomes; and develops recommendations, policies, procedures, and required adverse-action notices.
Requirements
- Associate’s Degree in Nursing.
- At least five years of clinical experience.
- At least five years of experience in case management, utilization management, and/or quality improvement.
- Current, unrestricted Registered Nurse (RN) licensure in the state of practice.
- Beginning-level experience with Excel, Word, and PowerPoint.
- Experience in data analysis and trending.
- Knowledge of utilization management standards and practices.
- Communication skills, attention to detail, and ability to work independently and within a team environment.
- Management, supervisory, and leadership skills or experience.
- Familiarity with the health care field.
- Critical listening and thinking skills.
- Training and teaching skills.
- Strategic management skills.
- Negotiation skills or experience.
- Proper grammar usage and technical writing skills.
- Change resiliency and time management skills.
- Proper phone etiquette and customer service orientation.
- Decision-making and problem-solving skills.
Nice To Haves
- Bachelor of Science in Nursing (BSN).
- Two years of utilization management experience.
- Managed care experience.
Responsibilities
- Assist in coordinating and managing the pre-determination process for medical and dental services.
- Ensure consistent application of authorization criteria and that decisions to deny or reduce services are made by health care professionals with appropriate clinical expertise.
- Assist in developing integrated service delivery and oversee utilization management data and processes, including decisions within allowable timeframes.
- Interact with providers and staff to manage benefits in alignment with state-based regulations, NCQA and/or URAC regulations, and CareSource policies.
- Review and revise workflows to maximize efficiencies.
- Monitor productivity and utilization trends.
- Oversee continuous quality improvement activities and ensure audits and staff feedback occur regularly.
- Regularly report utilization management regulatory requirements and ensure compliance with and reporting of all regulatory requirements.
- Maintain utilization management reporting and trend data.
- Analyze under- and over-utilization information for effects on member quality of care and outcomes, and formulate data-based recommendations.
- Develop, maintain, and update departmental policies and procedures; ensure notices of adverse action are provided in accordance with regulations.
- Audit pre-determination requests and cases for documentation and interrater reliability according to CareSource policy.
- Act as a liaison with other departments to support research and intervention.
- Perform other job-related instructions as requested.
Benefits
- May qualify for a bonus tied to company and individual performance.
- Comprehensive total rewards package.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
Education Level
Associate degree
