Manager Utilization Mgmt. - Remote -Kelsey- Seybold Clinics

UnitedHealth Group•Pearland, TX

1d•Remote

About The Position

Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation’s leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together. The Manager of Utilization Support Services provides direction and oversight of utilization review activities, including pre-certification, concurrent, and retrospective reviews to ensure effective management of inpatient care, discharge planning, and prior authorizations. Additional tasks include creation of successful processes and workflows to support effective quality outcomes and benefit maximization within the scope of responsibility. The Manager of Utilization Support will lead clinical services and work with cross functional teams to develop key performance indicators, identify over/under utilization patterns and/or deviation from established goals. Create solutions to enhance quality outcomes. Lead provider and health plan partnership initiatives. Establish processes and procedures to ensure contractual, regulatory (Federal/State) and accreditation entities. Utilize reporting tools to adequately assess production and quality results of individual staff members. Provides leadership for inpatient and prior authorization management applicable to future expansion and growth efforts. The Manager of Utilization Support Services will ensure Centers of Medicare & Medicaid Services, Texas Department of Insurance and applicable NCQA, AAAHC, and Health Plan standards are met. The Manager has responsibility for clinical data reporting, health plan delegation requirements, collection and analysis of bed day results, denial statistics and staffing education. The Manager works in collaboration with Medical Directors, Payor Support and Network Development Teams. Oversees all phases of development, organization, planning and implementation of projects/initiatives/workflows/processes to enhance quality-driven outcomes.

Requirements

Bachelor’s Degree in Nursing or equivalent experience
RN state of Texas, Valid TX DL
8+ years of nursing experience in support of Utilization Review or Case Management
5+ years in a supervisory/management role OR 5+ years of experience in Utilization Review or Case Mgmt. with 3+ years with Kelsey-Seybold
Knowledge of ICD-10 Coding methodologies, Managed Care payment methodologies, proficient in MS office products, and process improvement methodology
Proven excellent written and verbal communication skills

Nice To Haves

Master’s degree in nursing or related field
Supervisory or management experience in a Managed Care environment
Epic Experience
Proven computer literate
Master’s degree in nursing or related field
Supervisory or management experience in a Managed Care environment
Epic Experience
Proven computer literate

Responsibilities

Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines/criteria. Establish communication with Medical Director and physician reviewers for concerns applicable to medical necessity arise or request does not meet necessity per guidelines
Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services
Oversight of Utilization Management non-clinical staff duties; managing them in a professional and competent manner, ensure appropriate review and documentation of calls and faxes related to Utilization Review requests
Ensures appropriate training for incoming utilization review nurses
Performs all other related duties as assigned