Accountable for providing vision and strategy for inpatient utilization and prior authorization management activities designed to achieve quality and service-driven objectives. Oversees all phases of development, organization, planning and implementation of projects/initiatives/workflows/processes to enhance quality-driven outcomes.
DEPARTMENT: Health Services
REPORTS TO: Sr. Medical Director
- Provides direction and oversight to ensure effective management of inpatient care, discharge planning, and prior authorizations.
- Optimizes processes and workflows to achieve successful quality outcomes and benefit maximization within the scope of responsibility.
- Possesses the flexibility to act as a subject matter expert liaison for Clinical Services and/or a leader on cross-functional teams.
- Serves as an instrumental partner in development of key performance indicators. Monitors and tracks key performance indicators to independently identify over/under utilization patterns and/or deviation from expected results.
- Formulates strategic solutions to enhance quality outcomes.
- Executes periodic competitor utilization management program comparison and analysis to ensure WellCare's utilization management program maintains competitive edge.
- Develops processes and procedures to ensure department-wide compliance with contractual, regulatory (Federal/State) and accreditation entities.
- Provides leadership and support to front-line staff, supervisors and managers.
- Leads talent management activities to develop and cultivate future leaders.
- Promotes and improves environment of Provider and Health Plan partnership.
- Ensures monitoring and tracking tools are in place to adequately link and assess production and quality driven work products and outcomes to individual performers.
- Serves as the subject matter expert for inpatient and prior authorization management for future expansion and growth efforts
- Develops formal policies, procedures and workflows that effectively guide work activity.
- Develops formal department-specific new employee orientation and training programs.
- Chairing monthly UM meetings.
- Performs other duties as assigned.
- Required a Bachelor's Degree in Nursing (BSN), or equivalent work experience
- Preferred a Master's Degree in Nursing
- Required 7 years of experience in acute clinical/surgical experience and/or behavioral health clinical setting
- Required 3 years of management experience in a managed health care setting
- Required current experience in utilization management to include pre-authorization, utilization review, concurrent review, discharge planning, and/or skilled nursing facility reviews
Licenses and Certifications:
- Intermediate demonstrated problem solving skills Independent problem solving to overcome barriers and meet deadlines
- Intermediate ability to work within tight timeframes and meet strict deadlines
- Intermediate ability to lead/manage others
- Intermediate demonstrated analytical skills
- Intermediate ability to work in a fast paced environment with changing priorities
- Intermediate demonstrated written communication skills
- Intermediate demonstrated interpersonal/verbal communication skills
- Intermediate ability to create, review and interpret treatment plans
- Intermediate ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Intermediate demonstrate effective critical thinking and decision making skills
- Intermediate ability to communicate on any level required to meet the demands of the position
- Intermediate ability to correctly write business letters and comprehensive reports
A license in one of the following is required:
- Required Licensed Registered Nurse (RN) in state of practice
- Preferred Utilization review/management certification, or equivalent professional certification
- Required intermediate Microsoft Excel
- 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)
- Required Intermediate Microsoft Visio