About The Role
The Manager, Utilization Management (UM) will manage the Utilization Management team consisting of Clinicians and Non-Clinical support staff. The ideal candidate will have a strong clinical background within a managed care setting including a high-level understanding of prior authorization processes including inpatient/concurrent reviews, outpatient, and retrospective reviews.
Primary Responsibilities
Coordinate day to day operations of the Utilization Management team.
Serve as the primary contact for day-to-day operational escalations related to the Utilization Management program.
Establish and maintain positive intradepartmental and client relationships (i.e. account management, claims, customer service, intake…).
Contribute to development and maintenance of Utilization Management policies, standard operating procedures, and job aids that align with regulatory requirements.
Perform timely reviews of Utilization Management policies, standard operating procedures, and job aids to ensure accuracy and alignment with regulatory requirements.
Facilitate training for UM team members including Nurses and Coordinators on systems, departmental processes, and policies.
Facilitate ongoing quality oversight, education and performance improvement for team members.
Partner with Clinical Program leaders to address audit results to ensure compliance with regulatory and internal policy requirements.
Identify, solution, and implement new initiatives to improve the Utilization Management workflow. This may include intradepartmental collaboration and alignment across functional teams.
Responsible for addressing internal and client escalations as needed to the Director of Clinical Programs and VP of Clinical Operations.
Conduct routine team meetings.
Perform routine 1:1 discussion with individual staff members providing performance feedback throughout the year with the purpose of proactively addressing proficiency, competency, quality of documentation and understanding of expectations.
Support the development of downstream leaders through mentoring and training.
Other duties as assigned.
Essential Qualifications
Active and unrestricted license as a Registered Nurse (RN)
Bachelor’s degree in nursing, (or equivalent experience within managed care environment)
5 or more years of professional experience, including 3+ years in Utilization Management leadership experience.
Experience with accreditation organizations (URAQ/NCQA)
Organized with the ability to define and solve problems, collect data, establish facts, follow-up, and make recommendations for current and future needs.
Strong team and leadership skills
Must be detail oriented and have strong organizational and time management skills, and the ability to work independently.
Proficient in Microsoft Word, Excel, and Outlook.
Preferred Qualifications
Prior Experience with leadership including Hiring, WFM, Staff Performance.
Experience working within a TPA environment.
Experience with Case Management
Familiarity with call center operations
Experience in health platform build and implementation.
General Knowledge of HIPAA Confidentiality Laws
All candidates should have a general knowledge of HIPAA confidentiality laws.
Equal Opportunity Employer
We are an Equal Opportunity Employer.