Manages the activities of supervisory associates and their subordinate work group(s) and/or exempt individual contributors for assigned area of Appeals responsibility. Plans, directs, and coordinates appeals on behalf of the Plan.
Education: Licensed Practical Nurse. BSN preferred.
Experience: 5 years experience in a utilization management setting with experience in ER/critical care, discharge planning and bedside care. 3 years in managed care. 1 years in a management/supervisory position
- Licensed Practical Nurse
- Registered Nurse (Preferred)
Special Skills (e.g. 2nd language): Strong clinical knowledge on broad range of medical practice specialties. Knowledge of Utilization Management principles and criteria sets such as InterQual, Medicare guidelines,etc. Ability to manage a team in a metrics driven environment. Demonstrated negotiation skills. Demonstrated ability in problem solving and communication. Previous experience working with treatment teams to meet the healthcare needs of participants. Knowledge of community, state and federal laws and resources. Ability to effectively present information and respond to questions from families, members, and providers.
Technical Skills/Requirements: Proficient in Microsoft Outlook applications, including Word, Excel, PowerPoint and Outlook. Ability to use proprietary health care management system.