- Effectively manage the daily operations, workflow, and supervise clinical and non-clinical staff to provide support for the care management programs (case management, utilization management, pre-authorization call center, and appeal process).
- Assist in developing strategic plan by partnering with Assistant Director and Fund management to identify opportunities (e.g. new programs) that have direct impact on clinical and financial outcomes.
- Access and analyze all processes on an ongoing basis to determine their effectiveness, eliminate inefficiencies, and make recommendations to senior management to improve workflow, operations, and staff performance.
- Coordinate activities between clinical programs, communication, and report requirements to maintain operational efficiencies and to be in compliance with the Department of Labor (DOL), Summary Plan Description (SPD) departmental protocols and clinical policies and procedures.
- Interact and collaborate with other departments (e.g. Claims and Provider Relations) in troubleshooting, problem solving, and exchanging information in conjunction with maintaining effective communication with providers and members. Participate in interdepartmental committees/meetings.
- Responsible for staff development, clinical orientation, ongoing education, and training programs to meet the changing needs of the Department.
- Continually assess clinical staff performance against internal and external departmental and industry standards.
- Perform additional duties and projects as assigned by managed
- Bachelor’s Degree in Nursing, Business or Health Care Administration or equivalent years of work experience required; plus
- Current New York State of Registered Nurse (RN) license required
- Previous management experience and CCM certification preferred
- Minimum five (5) years advanced or specialized work experience in care management programs (Utilization/Case Management/Appeals Programs) within a managed care organization, to include a minimum of two (2) years progressive leadership and management experience
- Strong medical/clinical background with e xperience working with Milliman/InterQual guidelines or other regulatory protocols (i.e. Medicare), claims processing, medical coding (ICD-9, HCPCS, CPT) and interpreting provider contracts
- Ability to make critical business clinical decisions independently.
- Ability to work with automated Prior Authorization system
- Working knowledge of Microsoft Office Suite
- Strong critical thinking and analytical skills with effective troubleshooting and problem-solving abilities
- Excellent time management and project management skills
- Effective verbal and written communication skills
- Ability to prioritize and be detail-oriented, multi-task and must strive in fast-paced environment
- Must meet performance standards including attendance and punctuality
1199SEIU Family of Funds - 13 months ago