Manages the Utilization Review Department within Health Services; clinical and non-clinical staff. Handles the day-to -day operations of utilization management, concurrent review and discharge planning.
- Responsible for assisting in the development, implementation and management of health services functions and in achieving department goals and objectives.
- Provides guidance and supervision to staff.
- May coordinate and manage utilization review function ensuring accurate and timely prior authorizations, concurrent and retrospective review activity.
- Responsible for process improvement implementation, quality initiatives, and daily operations of the department.
- Performs updates to policies and procedures that are compliant with CMS requirements and NCQA/URAC/ CMS/state Medicaid requirements.
- May audit and must comply with corporate, federal, and state policies, procedures, and confidentiality standards.
- Conducts analysis on department statistics and creates reports on the findings.
- May act as a liaison with internal departments, outside entities, including physicians, hospitals, health care vendors, social service agencies, member advocates, and regulatory agencies.
- Leads departmental meetings and cross departmental project teams.
- Coordinates coverage and cross training of functions.
- Serves as a subject matter expert and leads process improvement teams in the review and analyzing of process functions and implementing changes.
- Analyzes departmental data and participates in appropriate forums for sharing this data and leading initiatives relating improvements.
- Performs all HR related functions including time management, expense management, and performance management including those related to lower level managers.
- Provides departmental coverage in the absence of higher level managers.
Minimum: Degree in nursing or relevant area of study. Active Registered Nurse (RN) license. At least 2 years management experience. Motivated and forward thinking.
Preferred: Managed Care experience. Hospital UM experience.
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