Manager Utilization Management - Health Plan Admin

Summary:

The Manager of Utilization Management supervises and leads the Utilization Management Department, including planning, organizing, and coordinating the activities of the Utilization Management program. Requirements include demonstrating knowledge of the managed care environment, Utilization Management and Medical Necessity Review standards and programs. Ability to develop and manage within budgetary guidelines. This Job includes daily clinical discretionary capacity that has potential to affect the financial well being of the health plan.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
  
• Responsible for all management aspects of the Utilization Management department (Utilization Management), including managing and supervising the selection, training, development, appraisal, work assignments, staffing, and productivity of UM staff.
  
• Responsible for daily operations of the UM department.
  
• Responsible for all reporting and report preparation functions within the Utilization Management department, including monthly reports to leadership.
  
• Responsible for ongoing compliance with existing contractual and regulatory standards within the Utilization Management Department.
  
• Ensures application of existing review criteria in the Utilization Review Process.
  
• Responsible for ongoing evaluation and improvement of work processes, within the department to ensure optimum potential of the department and associates.
  
• Participates in the development, implementation, and evaluation of utilization and Care Management (C.M.) Programs as part of annual strategic initiatives and reporting.
  
• Supervises daily activities of UM clinical staff, individually and as a team in collaboration with Care management and leadership to ensure the following objectives are met.
  
• Responsible for employee satisfaction survey completion within the UM Department.
  
• Responsible for Utilization Management staff performance reviews.
  
• Presentations to internal and external stakeholders regarding data and benchmarks.
  
• Must be proficient with Outlook, Excel, and PowerPoint (or similar presentation software).
  
• Other duties relevant to UM or CM which may be assigned by leadership.

Job Requirements:

Education/Skills

• Associate degree required.
  

• BSN preferred.

  
  

Experience

• 3 years in managed care or health plan utilization management department with leadership experience.
  
• 5 years of clinical nursing experience.
  
• Experience with CMS, NCQA, MCG/Interqual, and review hierarchy required.
  

• Department of Defense experience preferred.

  
  

Licenses, Registrations, or Certifications

• MCG Certification (or willingness to obtain).
  
• Current RN License is required.

Work Type:

Full Time

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