Direct and manage the Utilization Management services, oversee all aspects of Utilization Management, ensure efficiency of the workflow for team members, and ensure quality cost effectiveness.
Amalgamated Medical Care Management (formerly known as Alicare Medical Management) is ushering in a brand new chapter with a new and exciting leader. Our new president has adopted a culture which not only continues to provide the highest standards of patient care, but also is employee-centered with concern for each individual’s positive work experience and career advancement goals. In addition to benefiting from an attractive compensation package, staff members can expect a top-notch working environment that fully supports, respects, and values each member.
The Manager of Utilization Management is responsible for the overall strategy, operational performance and outcomes of the department’s activities. Develops, directs and monitors all Utilization Management (UM) and Clinical Medical Policy (CMP) programs that serve all Neighborhood members. Oversees and manages all UM vendors with full responsibility for meeting organizational goals for UM metrics and performance. Collaborates across the enterprise and with clients to ensure that objectives are aligned, business strategies are delivered and financial, compliance, and quality objectives are met.
- Directs the day-to-day medical management utilization and related compliance functions (CMS, state regulations, URAC)
- Prepares for, and directs, the URAC accreditation process, including all documentation required for desktop review and on-site evaluation.
- Ensures 100% compliance with all federal, state, regulatory and contract requirements
- Develops, executes and evaluates work plan for area of responsibility
- Assists in preparing and analyzing monthly, quarterly and annual utilization reports, identifying over and underutilization patterns and proposes and implements effective interventions to address UM issues to meet national or client benchmarks
- Monitors monthly utilization patterns; identifies outliers and puts in place program(s) to address outliers
- Monitors and evaluates staff UM decision-making by analyzing quarterly reviews, overturned appeals, physician decision trends, provides reports on performance and recommendations for needed improvements
- Develops medical utilization review policies, procedures and ensures annual review and revision
- Develops utilization review process for new lines of business
- Collaborates with Medical Director (MD) or physician reviewers to resolve complex medical review issues, as needed
- Engages in on-going performance management with staff including coaching, mentoring, development and succession planning.
- Identifies and recommends opportunities for improvement and implements process improvement activities
- Other duties as assigned
- Current NH RN license.
- College degree and/or nursing diploma.
- 4 years utilization review experience.
- 3 years management/supervisory experience and demonstrated leadership/management skills in managed care.
- Certification is nursing specialty preferred.
- Understanding of URAC accreditation highly desired.
- Membership in professional organization (i.e. ANA, AAMC) highly desired.
- Able to communicate with internal staff, external clients and healthcare providers.
- Conflict management/problem-solving skills.
- Strong and effective written, verbal and interpersonal communication skills.
- Able to work effectively with minimum supervision.
- Effective use of time management skills.
- Works well as a team player.
- Able to keep team focused at striving toward organization goals.
- Able to provide direction to team members.
- Highly organized self-starter.
- Extensive knowledge of insurance industry, benefit design and coverage issues.