This is a full time, exempt position with responsibility to manage and lead the Utilization Management Department, including the hiring, training, productivity, and ongoing management support to staff. This role will also ensure that health care services are administered with quality, cost effectiveness, and compliance to plan guidelines are maintained.
Position Responsibilities
Develop protocols that meet the needs of our customers and that meet or exceed industry benchmarks, as evidenced through Key Performance Indicators and reporting to SIHO leadership and stakeholders.
Coordinates and supervises the activities of the Utilization department.
Act as primary strategist for continuous improvement in Utilization Management regarding operational quality & efficiency, inventory monitoring, productivity, and quality of administrative service.
Works closely with provider stakeholders to implement processes and effective collaboration that aids in jointly providing high quality care and service to SIHO membership.
Guidance and Interaction with Utilization Management Staff and SIHO Medical Director(s) as needed to ensure proper medical necessity decisions are made in a timely manner.
Facilitate and lead, in partnership with Director, Medical Management, oversight functions, including working meetings with SIHO’s Quality Improvement Committee, the development and implementation of Prior-Authorization requirements, Coverage Recommendations, and Preventative Health Benefit guidelines.
Coordinate with colleagues on Member/Provider Navigation, Account Executive assistance, New Group Implementation/Configuration, and additional strategic initiatives as applicable
Support and lead internal teams to ensure reporting and department compliance requirements are completed in a satisfactory manner to CMS and other organizations, as applicable.
Review and revitalize Utilization Management/Review and other applicable Medical Management policies and practices on an annual basis or as necessary and applicable to industry regulations
Assists with maintaining appropriate staffing needs, team resources and references, personnel recruitment, retention, corrective action, and professional development.
Work with other departmental leaders to support SIHO Medicare Advantage: Lead Internal and External clinical reporting requirements of Program.
Qualifications
Candidacy Requirements:
Bachelor’s Degree in Nursing or related required; Graduate degree encouraged
Proven leadership experience within Utilization Management, Care Management, and/or Quality Improvement departments
Demonstrable experience implementing and leading operational change in previous organization(s)
Background in operations, operational efficiency, and department KPI reporting.
Verbal and written communication skills including discussing medical needs with members and interfacing with internal staff/management and external partners
Dedicated to quality patient and member outcomes
Ability to collaborate effectively with staff, providers, and a diverse group of leaders
Commitment to support and maintain confidentiality in accordance to HIPAA guidelines
Ability to motivate staff and co-workers and introduce new processes to staff
Must stay current on all clinical certifications and other continuing education requirements
Preferred Candidacy Skills
Certification in Case Management, Training, Project Management, or nationally recognized health care certification.
5+ years of experience in a Managed Care Organization
Drive to streamline processes and interest in long-standing process improvement