Sr Mgr, Clinical Care

Oversees the day to day operations for inpatient utilization, outpatient utilization and prior authorization management activities for multiple markets designed to achieve quality and service driven objectives.

Reports to: Dir. Utilization Management

Department: HI-Health Services

Location: Kapolei, HI.


Essential Functions:

  • Manages and optimizes workflows to achieve successful quality outcomes and benefit maximization within the scope of responsibilities.
  • Serves as an instrumental partner in monitoring and tracking key performance indicators to include identification of over/under utilization patterns and/or deviation from expected results for assigned area/markets.
  • Monitors processes and procedures to ensure compliance with contractual, regulatory (Federal/State) and accreditation entities.
  • Provides leadership and support to front-line staff and supervisors.
  • Monitors and tracks production and quality driven work products and outcomes to individual performers.
  • Provides guidance for inpatient, outpatient and prior authorization management for future expansion and growth efforts.
  • Leads talent management activities to develop and cultivate future leaders.
  • Performs other duties as assigned.
    Candidate Education:
    • Required A High School or GED
    • Preferred A Bachelor's Degree in Nursing or Healthcare field
    Candidate Experience:
    • Required 7 years of experience in a acute clinical/surgical setting, current experience in utilization management to include pre-authorization, utilization review, concurrent review, discharge planning, and/or skilled nursing facility reviews
    • Required 3 years of management experience
    • Preferred 3 years of management experience in a managed health care setting
    Candidate Skills:
    • Intermediate Demonstrated problem solving skills
    • Intermediate Demonstrated interpersonal/verbal communication skills
    • Intermediate Knowledge of community, state and federal laws and resources
    • Intermediate Ability to effectively present information and respond to questions from families, members, and providers
    • Intermediate Ability to work within tight timeframes and meet strict deadlines
    • Intermediate Demonstrated written communication skills
    • Intermediate Ability to lead/manage others
    • Intermediate Ability to effectively present information and respond to questions from peers and management
    • Intermediate Ability to lead/manage others in a matrixed environment
    • Intermediate Knowledge of healthcare delivery
    • Intermediate Knowledge of community, state and federal laws and resources
    • Intermediate Other Demonstrate effective critical thinking and decision making skills
    Licenses and Certifications:
    A license in one of the following is required:
    • Required Licensed Registered Nurse (RN)
    Technical Skills:
    • Required Intermediate Microsoft Word Proficient in Microsoft Outlook applications, including Word,Excel, Power Point and Outlook
    • Required Intermediate Microsoft Excel Ability to use proprietary health care management system
    • Required Intermediate Microsoft PowerPoint
    • Required Intermediate Microsoft Outlook
    • Required Intermediate Healthcare Management Systems (Generic)

      About us
      Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. WellCare is a Fortune 500 company, and in 2018, was recognized as a Fortune "World's Most Admired Company", ranking in the top five among the health insurance and managed care industry-a testament to the hard work and dedication of the company's nearly 9,000 associates who each day live WellCare's values and deliver on its mission to help its members live better, healthier lives. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.