Manager - Utilization Management Manager
About The Position
The Utilization Management Manager orients, guides, and oversees inpatient and outpatient case managers, the transition of care coordinator, Health Home Program (HHP), and inpatient support staff. The manager plans, develops, implements, evaluates, and refines case management interventions, and supervises case management and concurrent review personnel to ensure appropriate assessment, planning, and delivery of care for members. The role works with relevant departments to ensure that processes, programs, and services are completed efficiently and in a timely manner, in accordance with organizational policies and applicable state and federal regulations, including CMS and/or Medicare Part D and Special Needs Plan requirements. It supports continuous quality improvement, regulatory compliance, and the organization’s strategic objectives.
Requirements
- Bachelor of Science in Nursing; foreign medical graduates or applicants in health education or another mental/social health discipline may be considered, with a combination of experience and education considered in lieu of a nursing degree.
- Three years of clinical nursing experience.
- Two years of utilization management/utilization review experience.
- Knowledge of CPT and ICD-10-CM coding, M&R and/or other utilization management criteria, Microsoft Office software or equivalent, applicable state and federal laws, NCQA, Medicaid, and CCS.
- Experience interpreting utilization and benefits data.
- Strong communication and analytical skills; ability to organize work, determine priorities, and work independently and as a team member.
- Proficiency in applying highly technical principles and concepts.
- Demonstrated ability to interact with a wide variety of individuals and handle complex situations simultaneously.
- Ability to maintain confidentiality.
- Ability to use computers for prolonged periods.
Nice To Haves
- Master’s degree in Nursing.
- Two years of managed care experience.
Responsibilities
- Supervise case managers and concurrent review nurses in carrying out their roles and position descriptions.
- Assist case managers with coordinating care and services for a selected client population across the continuum of illness.
- Formulate, implement, and evaluate the knowledge base of case managers and concurrent review nurses.
- Analyze members’ case management goals, review plans for appropriateness, and identify anticipated outcomes.
- Develop and maintain a positive work climate that supports staff efforts.
- Help develop the philosophy, goals, and objectives for concurrent case management performance that meet clinical and financial requirements.
- Anticipate, recommend, implement, and evaluate policies and procedures related to case management and concurrent review.
- Contribute to organizational goals and objectives and support the strategic plan.
- Participate in developing clinician guidelines and incorporate the process into case managers’ roles.
- Interface with external agencies and provide appropriate information, consultation, and recommendations.
- Support continuous quality improvement and use quality improvement tools and strategies to solve problems.
- Identify case management patterns or trends with potential adverse effects on member interventions; develop corrective action plans and reevaluate outcomes.
- Attend educational and training programs to expand knowledge.
- Prepare regulatory reports in a timely manner.
- Attend committee meetings and ensure meeting minutes are accurate and detailed.
- Work on assigned projects and perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
