Ensures the integrity and high quality of utilization management services
Accepts utilization management assignments when work volumes or case complexities require managerial back up
Collaborates with the development and implementation of a quality management program, including an on-going internal quality control (IQC) system that provides on-going performance monitoring for compliance with contractual requirements, performance measures accreditation standards
Collaborates with medical affairs and staff in developing guidelines and protocols for clinical review staff in referring, consulting, and staffing cases/reviews with Medical Directors and physician/practitioner consultants and dentists.
Develops and implements, through collaboration with staff and other managers, the necessary operational policies and procedures to meet contractual requirements, customer expectations, accreditation standards, and organizational needs
Monitors and maintains adequate access by providers, customers, patients/clients, and others with staff in order to provide the timely provision of Utilization Review services
Reviews Utilization Review reports, appeal letters, and other sensitive documents to ensure they meet contractual requirements, accreditation standards, performance measures, timeframe requirements, and service standards %
Efficiently and effectively manages financial responsibilities
Develops and monitors the productivity standards for the staff to ensure there is efficient and effective delivery of services by the appropriate number and skill level of staff
Develops timely and appropriate budgets that include sufficient staffing and other resources to meet the contractual requirements, case/review volumes, service standards, and organizational goals
Ensures compliance with finance and accounting policies and procedures, which includes but is not limited to the delegations of authority
Initiates timely and appropriate managerial interventions to improve compliance with the budget when expenditures are not in line with budget
Monitors unbilled hours and open cases/reviews to ensure that there is timely, accurate, and appropriate billing by staff
Effectively works with customers, including business development activities
Participates in responses to requests for proposals (RFPs), product development, and other business development activities
Promotes, monitors, and improves positive customer service behaviors, communications, and attitudes by all staff in the provision of services to all stakeholders
Provides timely, appropriate, and responsive communications and interventions when necessary with providers, patients/clients, customers, and other stakeholders to resolve their concerns, questions, and issues
Represents the products/services of the department through the active participation in customer conference calls, customer meetings, and educational seminars
Complies with policies and procedures, administrative assignments and other projects
Develops, monitors, and reports on departmental goals, standards, and objectives through collaboration with the Vice President, Medical Director, Operations Director, staff, and other managers
Ensures that the Vice President, Operations Director or designee is informed in a timely manner regarding significant operational issues, performance measures, complaints/grievances, compliments, quality management initiatives, staffing concerns, and other relevant topics
Maintains compliance with organizational policies and procedures, including but is not limited to the strategic plan, organizational structure, confidentiality, safety, and complaint/grievance resolution
Monitors completion of timecards to ensure staff's accuracy, timeliness, and compliance with related policies and procedures
Required Skills
Intermediate MS Office Suite proficiency
Working knowledge of Medicaid, or commercial insurance preferred
Required Experience
Current, active, unrestricted RN licensure
BA / BS in a related field
Equivalent combination of education and/or work experience may be substituted
IQCI or certification in a medical management field preferred
At least 5 years of utilization/case management experience
At least 2 years of management experience, including financial management
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Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Health Care Provider
Industries
Staffing and Recruiting
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