Manager, Utilization Management - Must have a MA RN License

CareSource•Massachusetts WFH, MA

9d•$83,000 - $132,800•Onsite

About The Position

The Manager, Utilization Management is responsible for the oversight of all utilization management activities ensuring consistency of services and achievement of utilization targets. This role involves assisting in the coordination and management of the pre-determination process of medical and dental services, ensuring consistent application of criteria for authorization decisions. The manager will also develop integrated service delivery to members, oversee utilization management data and processes to maintain industry standards, and interact with providers and staff to manage benefits aligned with state-based regulations, NCQA and/or URAC regulations, and CareSource policies. Key responsibilities include reviewing and revising workflows, monitoring productivity and utilization trends, overseeing CQI activities, and ensuring compliance with all regulatory requirements. The role also involves analyzing under and over utilization information, developing and updating departmental policies and procedures, auditing predetermination requests, and acting as a liaison with other departments. The position requires a current, unrestricted Registered Nurse (RN) license.

Requirements

Associate’s Degree in Nursing is required
Minimum of five (5) years of clinical experience is required
Minimum of five (5) years of experience in one of the following is required: case management, utilization management, and/or quality improvement
Beginning Excel, Word and PowerPoint experience
Experience in data analysis and trending
Knowledge of utilization management standards and practices
Communication skills
Management and prior supervisory skills
Ability to work independently and within a team environment
Attention to detail
Familiarity of the health care field
Critical listening and thinking skills
Training/teaching skills
Strategic management skills
Negotiation skills/experience
Proper grammar usage
Change resiliency
Technical writing skills
Time management skills
Proper phone etiquette
Customer service oriented
Decision making/problem solving skills
Leadership experience and skills
Current, unrestricted licensure in state of practice as a Registered Nurse (RN) is required

Nice To Haves

Bachelors of Science in Nursing (BSN) is preferred
Two years of utilization management experience is preferred
Managed care experience is preferred

Responsibilities

Assist in coordination and management of the pre-determination process of medical and dental services; ensure the consistent application of criteria for authorization decision, and that decisions to deny or reduce services are made by a health care professional who has appropriate clinical expertise
Assist in the development of integrated service delivery to members and oversee utilization management data and processes to maintain industry standards and practices including decisions within allowable timeframes
Interact with providers and staff to manage benefits aligned 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 CQI activities and ensure audits and staff feedback occur at regular intervals
Regularly report all utilization management regulatory requirements
Ensure compliance with and reporting of all regulatory requirements
Maintain all utilization management reporting and trend data
Analyze under and over utilization information for impact on member quality of care and outcomes and formulate recommendations based on data
Develop, maintain and update all departmental policies and procedures; ensure notices of adverse action are provided in accordance with required regulations
Audit predetermination requests, cases for documentation and interrater reliability per CareSource policy
Act as liaison with other departments to assist with research and intervention
Perform any other job related instructions, as requested