Summary of Job: Direct oversight and accountability for the Medical Management Operations concurrent review utilization management function, ensuring accurate administration of benefits, execution of clinical policy and timely access to appropriate levels of care.
- Contributes to the overall success of concurrent review by promoting/advancing the Plan's mission of effectively facilitating inpatient care and improving outcomes.
- Direct accountability of end to end inpatient concurrent review ensuring compliance with State, Federal and NCQA requirements related to utilization management activities.
- Establishes and maintains standards for caseloads, department productivity targets while consistently improving quality and performance by actively deploying process improvements.
- Collaborates with up and down stream internal and external business partners to ensure consistent and effective workflows are in place, care management systems are aligned and drives changes as required.
- Responsible for creation, maintenance, revision and termination, as applicable, of all Medical Management concurrent review operating procedures and workflows.
- Identifies and analyzes trends in concurrent outcomes data which negatively impact cost and/or quality. Submits recommendations/suggestions to affect negative trends.
- Ensures that an effective monitoring program is in place routine in collaboration with the department Quality and Training team.
- Primary liaison to Clinical Administration; direct contact and accountability for executing against the concurrent components of the utilization management program.
- Develops and maintains an advanced working knowledge of facility contracts that govern and/or impact concurrent review processes.
- Acts as a subject matter expert for concurrent review. Leads and represents the department for projects and initiatives, including planning and cost analyses.
- Responsible for annual budget, maintaining or exceeding goals.
- Collaborates with Clinical Administration on UM/CM related initiatives to foster alignment of medical management strategies including alternatives for care to ensure high quality cost-effective continuum of care.
- Works collaboratively with facilities and actively engages with the Provider Network Management teams, as appropriate, to achieve desired outcomes.
- Actively directs the team management and Quality Management and Training team to ensure the development of initial and ongoing employee orientation as well as on-going training needs for all department staff and organizes training sessions throughout the year.Serves as a role model to others exemplifying high performing work standards. Mentors staff regarding the care and/or utilization management plan for complicated cases.
- If applicable; researches, develops, implements and evaluates Medical Management Operations educational initiatives to members or providers. Coaches peers through the same process.
- Pro-actively remains current with new medical information and updates to evidence-based clinical guidelines, medical protocols, provider networks and other online resources required for making coverage determinations and care coordination.
- Actively participates on clinically focused committees as needed.
- Active participation and attendance for concurrent review rounds.
- Performs other related projects and duties as assigned.
- RN, licensed in New York or Connecticut. Bachelor's Degree in health care
- At least 10 years of clinical and managed care experience
- At least 5 years of successful previous managerial experience with ability to work in a matrix management environment
- State of the art knowledge of care/utilization management tactics
- Strong oral and written communication and interpersonal skills. Consistently demonstrates mastery of Motivational Interviewing techniques
- Strong organizational skills
- Strong knowledge of Microsoft Office products including Word, Excel, and Access
- National certification in Case Management or Chronic Condition education preferred