Manager, Utilization Management

A Manager within Clinical Services is responsible for overseeing day to day operation of the clinical staff for Medical Utilization Management for all lines of business. They are responsible for ensuring proper staffing levels, work assignments, performance evaluation of staff, serving as a subject matter expert on benefits, policies and operational procedures within their line of business and ensuring that all medical operations are consistent with The Health Plan policies and procedures.

Required:

Registered Nurse with at least five (5) years' experience.

Must have critical care or other acute care experience.

Active Ohio or West Virginia multistate licensure which must be maintained throughout employment, including compliance with State Boards of Nursing continuing education policy. Other licensure required as company expansion warrants.

Experience with care coordination, discharge planning, clinical documentation, and utilization review

Knowledge of InterQual criteria and patient status changes.

Strong communication and leadership skills.

Knowledge of accreditation standards, federal and state standards/regulations.

Considerable knowledge of clinical service UM policies and procedures.

Ability to analyze data and employ approved management techniques and statistical tools to obtain maximum effectiveness, efficiency and information.

Ability to interpret established policies into operating procedures and to execute complex case navigation programs.

Ability to coordinate effectively various functions and activities for maximum cooperation and efficiency.

Ability to direct, instruct and advise staff in the approved methods, procedures and practices employed in effective utilization management.

Ability to receive and effectively react to day-to-day problems presented by staff as well as others.

Effective organizational, oral and written communications skills, problem solving, program development, computer skills, strong leadership and team building skills.

Ability to work with a variety of disciplines and levels of staff across departments.

Ability to establish priorities, meet deadlines, develop and manage the department's productivity in the management of work assignments.

Ability to form positive, collaborative relationships with members of the management team.

Desired:

Certification in managed care, case management or related clinical certification desirable.

Utilization Management, Quality Improvement or Disease Management experience desirable.

Active licensure in other states as requested.

Responsibilities:

Orient new staff to department policies and procedures and system functions.

Identifies appropriate staffing levels and assignments. Monitor performance criteria for staff members.

Assists Director in implementation of departmental plans, programs and related reporting..

Review utilization performance in relation to established goals. Implements changes to effect continual improvement in services provided by performance of routine interrater monitoring on nurse navigators and support staff.

Reviews utilization management functions including preauthorization and inpatient navigation functions to affect continual improvement in services provided by performance of routine interrater monitoring on nurse navigators.

Interprets benefits, laws, policies, procedures and objectives; ensures compliance with requirements.

Shares with Director the responsibility of collecting, analyzing, evaluating and presenting clinical management and operational data to various audiences.

Assists the Director in development, implementation and evaluation of yearly work plan.

Participates on assigned committees.

Directly responsible for performance evaluations of nurse navigators.

Collaborates with Director to develop mechanisms for staff development and make changes to keep current with new regulations, policies and trends.

Maintains skills to allow for coverage utilization management as needed and/or staff shortage;

Identifies and reports potential high cost cases to the reinsurance carrier by use of hospital review, prior authorization requests or claims cost report.

Conduct clinical audits and provide necessary feedback.

Participates in activities related to regulatory functions as directed by the Manager of Clinical Compliance and/or Director related to CMS, BMS, Qlarent, NCQA and others related to all lines of business.