This position is accountable for all aspects of the Utilization Management and Care Management programs. The responsibilities of this position are to lead and direct all activities related to the development, implementation, and maintenance of an effective team, which encompasses Utilization Management and Care Management. The incumbent has exemplary management skills and is an effective leader of his/her team. The Managers oversight of UM and Care Management functions, which includes pre-authorization, pre-determination, retro review, denials and appeals, pre-existing reviews, and care management activities.
Job Duties & Responsibilities
Ensure compliance with the standards set by the Bureau of TennCare, NCQA, URAC, and other regulatory and accrediting bodies.
Administers Utilization Management programs for all lines of business within VSHP to include:
Manages staffing and resources to comply with turn around time standards
Administers and review productivity levels to increases them as system upgrades accelerate the authorization process.
Administers quality standards that have been established for all Utilization Management, TOC, UM Nurses and support staff.
Participates as needed in rotation of the 24-hour/day call duty to process after-hour authorization requests
Responsible for all lines of business managed in the Government Medicaid Division
Reviews productivity standards quarterly, and continuously increase them as system upgrades accelerate the authorization process.
Administers quality standards that have been established for all staff functions.
Internal customer education, consultation, and problem resolution and prevention.
External customer education, consultation, and problem resolution and prevention.
Regular meetings with contractor. Proactively seeks face-to-face interaction to establish good working relationships and prevent communication barriers.
Meet with hospital executives and management, physicians and their office staff, ancillary provider management, community resources (health departments, Dept. Children Services, etc.) to resolve issues and process barriers.
Accompanies Medical Directors to provider meetings to educate, consult, and problem solve with the providers as well as to build and maintain effective working relationships.
Medical Directors, Chief Financial Officers, Chief Executive Officers, Directors, and Vice Presidents.
Discusses problems and issues with members and providers to find appropriate resolution.
Claims and Customer Service interfaces include designing and overseeing the implementation of new processes to assure that authorization entries contribute to a high first pass rate for claims. Identifies and directs changes to increase claims processing accuracy.
Participates in review and development of RFI's and RFP's for potential new business.
Knowledgeable of claims, membership and provider subsystems.
Performs delegated review audits of contracted companies as the Delegated Oversight Committee calls upon medical management expertise.
Participates in corporate committees as appointed by the Director.
Contributes to the development of, and the review and revision of policies and procedures for Standards and Compliance Dept.
Contributes to the development of, and the review and revision of, program descriptions, provider manuals, communication materials, and annual reviews.
Overall responsibility for productivity and quality performance within department. Directly responsible for the implementation of divisional initiatives and projects.
Overall responsibility for clinical reviews and reports.
Proactively develops and updates process improvement plans for internal and external customers,
Responsible for the continued development of the Medical Management Department.
Registered Nurse with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.
BS degree in Nursing or related healthcare field preferred, or successful track record of management experience.
5+ years experience in the healthcare industry required
At least 3 years of recent experience in Utilization Management
At least 3 years of recent experience in Case Management
Minimum of 3-5 years of supervisory/management experience - preferably in a regulated in environment
CCM Certification is required. If not certified, certification must be obtained within one year.
At least 2 years of recent experience (in the last 5 years) in a position demonstrating critical thinking skills managing patients within an acute care environment using Milliman and InterQual Criteria preferred
Regular overnight travel is required
Various immunizations and/or associated medical tests may be required for this position.
Health Care Service Corporation (HCSC) is a licensee of the Blue Cross and Blue Shield Association. The mutually owned company consists of...