Oversees the day to day operations for inpatient, outpatient and prior authorization management activities to achieve quality and service driven objectives.
Reports to: Dir. Utilization Management
Department: Health Services-NE
Location: Untied States
- 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.
- 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).
Licenses and Certifications:
- 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
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)