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Oversees the day to day operations for inpatient, outpatient and prior authorization management activities to achieve quality and service driven objectives.
Supervises a staff of nurses to achieve successful quality outcomes and benefit maximization towards members care.
Supervises processes and procedures to ensure compliance with contractual, regulatory (Federal/State) and accreditation entities.
Provides leadership and support to front-line staff.
Monitors and tracks production and quality driven work/outcomes on assigned staff.
Monitors associates' performance, productivity and quality through standard reports.
Conducts one-on-one coaching and provides associates feedback routinely and as needed.
Provides counseling/corrective action procedures when required.
Maintains documentation of performance including attendance and disciplinary actions.
Provides significant input into associates' performance evaluations and hiring/terminations.
Manages the E-time process - including training and education.
Conducts training for new associates and re-training based on changing policy and procedure
Prepares and completes projects, reports and assignments as needed to meet departmental goals and initiatives.
Attends company meetings in absence of manager.
Makes process improvement recommendations to management.
Act as primary contact for escalated calls and/or escalated issues or that require additional research and/or special handling.
Investigates issues of an unusual nature and proposes solutions in a clear and concise manner.
Demonstrates appropriate customer-care skills such as empathy, active listening, courtesy, politeness, helpfulness and other skills as identified.
Performs other duties as assigned.
Additional Responsibilities:Candidate Education:
Required A High School or GED
Preferred A Bachelor's Degree in a related field
Required 4 years of experience in A clinical or utilization management setting with exposure to pre-authorization, utilization review, concurrent review, and/or discharge planning.
Required 1 year experience in leading/supervising others In a clinical or managed care setting (preferred) where you functioned in a team lead or senior capacity, providing mentoring, training, support, and guidance and functioned as a subject matter expert (SME).
Intermediate Demonstrated problem solving skills
Intermediate Knowledge of community, state and federal laws and resources Knowledge of community, state and federal laws and resources
Intermediate Ability to effectively present information and respond to questions from families, members, and providers 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 interpersonal/verbal communication skills
Intermediate Demonstrated written communication skills
Intermediate Ability to lead/manage others
Intermediate Ability to effectively present information and respond to questions from families, members, and providers
Intermediate Ability to effectively present information and respond to questions from peers and management
Intermediate Other Previous experience working with treatment teams to meet the healthcare needs of participants
Intermediate Ability to lead/manage others in a matrixed environment
Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
Intermediate Other Knowledge of utilization management principles and criteria sets
Intermediate Other Strong clinical knowledge of broad range of medical practice specialties
Licenses and Certifications: A license in one of the following is required:
Required Licensed Registered Nurse (RN)
Required Intermediate Microsoft Excel Proficient in Microsoft Outlook applications, including Word,Excel, Power Point and Outlook
Required Intermediate Microsoft Word Ability to use proprietary health care management system
Required Intermediate Microsoft Outlook
Required Intermediate Microsoft PowerPoint
Required Intermediate Healthcare Management Systems (Generic)