Program Manager - Utilization Management

Independent Health-posted about 1 year ago
$85,000 - $105,000/Yr
Full-time • Mid Level
Buffalo, NY
Insurance Carriers and Related Activities
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The Program Manager - Utilization Management (UM) is responsible for managing, implementing, and executing UM programs within Independent Health. This role involves drafting and modifying medical and administrative policies, ensuring compliance with regulations, and overseeing the implementation of changes across the organization. The Program Manager will collaborate with various departments to assess and improve the utilization management process, manage medical expenses, and report on outcomes and recommendations to senior leadership.

  • Manage the implementation and execution of UM programs.
  • Draft and identify necessary changes in medical and administrative policy.
  • Obtain approval for changes from the Medical Director and governing committees.
  • Oversee the implementation of UM programs throughout the organization.
  • Identify recommended changes to the UM Medical Management program and seek approval for implementation.
  • Ensure accurate implementation and configuration of UM programs.
  • Collaborate with multiple departments to assess and improve the utilization management process.
  • Analyze utilization trends and costs, communicating recommendations to leadership.
  • Develop and maintain medical necessity criteria utilizing evidence-based literature.
  • Monitor utilization trends and clinical appropriateness, making necessary changes.
  • Bachelor's degree required; Master's degree preferred.
  • Five years of experience in health plan managed care operations required.
  • Registered Nurse (RN) with active, unrestricted NYS license strongly preferred.
  • Certified Professional Coder (CPC) is strongly preferred.
  • Knowledge of clinical care management processes and claims processing.
  • Experience with MCG and the MCG Modification tool functionality.
  • Ability to define problems and analyze data critically.
  • Knowledge of ICD-10, CPT, and HCPCS coding.
  • Excellent verbal, written, and interpersonal communication skills.
  • Multi-dimension project management experience preferred.
  • Experience in development of clinical processes and SOPs.
  • Scorecard incentive eligibility
  • Full range of benefits
  • Generous paid time off
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