Department: Population Health Solutions
Reports to: VP, Medical Management HS Administration
Location: 8715 Henderson Road, Tampa FL 33634
Additional possible locations: Houston, TX, Phoenix, AZAccountable 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/work flows/processes to enhance quality-driven outcomes. Oversees utilization management and discharge planning for all markets that are not self-contained. Works collaboratively with the market medical directors, presidents and nurse executives to ensure consistency in our review process.
Additional Responsibilities: Candidate Education:
- Provides direction and oversight to ensure effective management of inpatient care, discharge planning, and prior authorizations for medical or behavioral health.
- Optimizes processes and work flows 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 Health 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 work flows that effectively guide work activity.
- Develops formal department-specific new employee orientation and training programs.
- Provides direction on a corporate level for the interface between EMMA and Excelys so that authorizations can map to claims.
- Responsible for expanding UM on a regional basis.
- Responsible for assessing the market's need for onsite concurrent review, working collaboratively with the market to place the staff in facilities.
- In collaboration with our UM Medical director and VP, assists in identifying and then implementing strategies to correct trends of either over or under utilization.
- Serves as a key member in the Clinical Services Organization's leadership team.
- Collaborates with operations to decrease turnaround times on authorization requests coming through the intake unit.
- Collaborates with appeals and grievances to identify issues with current authorization processes and to identify trends which could improve application of criteria and processes.
- Chairs a monthly Utilization Management meeting with representatives from all lines of business to identify and resolve issues impacting members, providers and claims payment.
- Ensures that we are actively engaging on Medical Director reviews and strategies when an external review source is needed so that timely medical determination can be made.
- Oversees UM portion of readiness reviews, External Quality Review Organization (EQRO) reviews and NCQA reviews for the markets managed by corporate UM.
- Serves as the primary resource for determining our future UM processes for the PEGA system conversion.
- Performs other duties as assigned.
- Required A Bachelor's Degree in Nursing (BSN), Health Administration, Business, or related field
- Required or equivalent work experience
- Preferred Other MBA, MPH or MHA
- Required 7 years of experience in acute clinical/surgical experience
- Required 5 years of management experience in a managed health care setting
- Required Other current experience in utilization management to include pre-authorization, utilization review, concurrent review, discharge planning, and/or skilled nursing facility reviews
- Required 5 years of experience in in progressively challenging positions
Licenses and Certifications:
- Advanced Demonstrated problem solving skills Independent problem solving to overcome barriers and meet deadlines
- Advanced Ability to work within tight timeframes and meet strict deadlines
- Advanced Ability to lead/manage others
- Advanced Demonstrated analytical skills
- Advanced Ability to work in a fast paced environment with changing priorities
- Advanced Demonstrated written communication skills
- Advanced Demonstrated interpersonal/verbal communication skills
- Advanced Ability to create, review and interpret treatment plans
- Advanced Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Advanced Other Demonstrate effective critical thinking and decision making skills
- Advanced Other Ability to communicate on any level required to meet the demands of the position
- Advanced Other Ability to correctly write business letters and comprehensive reports
A license in one of the following is required:
- Required Licensed Registered Nurse (RN)
- Preferred Other Utilization review/management certification, or equivalent professional certification
- 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 Microsoft Visio
- Required Intermediate Healthcare Management Systems (Generic)