Responsible for the daily supervision of pre-authorization to include the telephone/fax authorization and retrospective claim review processes. Serves in an active managerial role to assist in the development; implementation; and evaluation of the utilization management process.
- Provides oversight and direction to the staff members including staffing; training; monitoring; and evaluation.
- Reviews the timeliness; appropriateness; and medical necessity of utilization processes performed by the staff. Prepares reports detailing the monitored activities.
- Actively participates in the development; implementation; and oversight of the utilization management activities for the Plan. Serves in an adjunct role for policy and procedure development and implementation.
- Assists in the identification of issues which may adversely impact the attainment of department goals (i.e.; telephone answer time; talk time; abandonment rates; etc.)
- Collaborates with other departments to educate providers/vendors and members regarding participating network providers/specialists; benefits and utilization management policies and procedures.
- Attends meetings with internal work groups and external business parties.
- Assists in the identification and reporting of potential quality improvement issues. Responsible for assuring these issues are reported to the Quality Improvement Department.
- Performs other duties as required.
- Registered nurse with current license in good standing in the state where job functions are performed.
- Bachelor's degree or equivalent experience.
- Previous experience (usually 2+ years) in utilization management.
- Significant experience (usually 3+ years) clinical experience.
- Previous experience (usually 2+ years) supervisory experience.
- Proficiency in medical terminology and ICD-9 and CPT coding preferred.Coventry Health Care is an Affirmative Action/Equal Opportunity Employer; and we are committed to building a talented and diverse team.Coventry Health Care is an Affirmative Action/Equal Opportunity Employer; and we are committed to building a talented and diverse team.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Primary Location: Tampa, FL, US
Organization: 10000 - Coventry Health Care - Corp
Job Posting: 2012-07-24 00:00:00.0
Job ID: 174742k
In May of 2013, Coventry became a part of Aetna. We are excited to join together with common values and a common mission: empowering people...