Summary: Plans, organizes, and manages the case management, medical review, utilization review, partnership for quality programs, appeal management, audit, and/or health education programs. Analyzes utilization trends. Develops and implements action plans to improve care coordination, utilization and quality.
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 handle grievance and/or appeal process. May coordinate and manage utilization review function ensuring accurate and timely prior authorizations, concurrent and retrospective review activity. Responsible for implementing and clinical coordination of programs and interventions that will prevent unnecessary admissions, readmissions, and overutilization in a healthcare system, putting into practice the Institute of Healthcare Improvement’s Triple Aim TM of better care, better health, and lower costs.
May be responsible for increasing patient compliance through education to optimize heath and minimize complications and exacerbation. 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/CMSA 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 Requirements: Bachelor’s degree or certification in relevant practice areas. At least five years experience in managed care. For Clinical positions, at least six years of clinical experience.
Preferred Requirements: Master’s degree or in process of obtaining advanced degree. Active Registered Nurse (RN) license, Licensed Physical Therapist (LPT), Licensed Respiratory Therapist (LRT), Licensed Social Worker (LSW), Registered Dietitian (RD), Pharmacist, or Psychologist.