Manager Utilization Management
Primary Job Purpose
Plans, directs, and manages the activities of the utilization management professional and support staff. Oversees staff directly or through subordinate supervisor(s). Provides leadership to set performance standards and ensure effective and efficient execution of utilization management programs across all Regence plans, including prospective, concurrent, retrospective review and/or post service claims review and bill audit procedures. Represents the department in interactions with all levels of management, vendor partners, clients, providers, government officials, and outside consultants.
At Cambia, our values are fundamental to achieving our Cause of transforming the health care industry. They guide our actions and bring diverse perspectives together to improve the health care journey better for those we serve. All eight values are equally important and linked to the others: Empathy, Hope, Courage, Trust, Commitment, Innovation, and Accountability. These values are not just words on paper - we live them every day.
Responsibilities & Requirements
Competencies and Knowledge:
- Ability to identify issues, opportunities, and effective solutions and collaborate with other departmentsto improve processes and/or results.
- Demonstrated competency in resource and project management: budgeting, organizing work, providing leadership to staff, establishing measures for success, and managing to deliverables.
- Ability to develop and lead a team including: hiring, goal setting, coaching and development (including supervisors and/or employees who may be in multiple locations or work remotely).
- Ability to communicate effectively, verbally and in writing, including meeting facilitation and presentations with employer or provider groups.
- Familiarity with health insurance industry trends and technology.
- Demonstrated competency in clinical case management and utilization management practices.
- Experience with statistical analysis and their application in utilization management programs.
Normally to be proficient in the competencies listed above:
A Manager of Utilization Management would have a bachelor's degree in nursing or related field, masterspreferred, 5 years of clinical care experience, 5 years of leadership experience and 7 years of insurance industry experience or equivalent combination of education and experience.
Required Licenses, Certifications, Registration, Etc.
Current unrestricted Registered Nurse (RN) Licensure, in a state or territory of the United States.
General Functions and Outcomes
- Leads the development and execution of effective utilization and/or payment review management policies, procedures and standards. Oversees the implementation of policy updates or process improvements as needed to ensure quality and service excellence.
- Handles all management level responsibilities for staff, including performance reviews, employee development, hiring, coaching, counseling, and retention. Develops supervisors and participates in talent management activities.
- Regularly communicates organizational objectives and team goals. Monitors results and metrics to ensure deliverables are met and compliance with department and regulatory standards. Collaborates withother leaders and across departments to resolve issues.
- Manages financial targets and department budget, authorizes expenditures, monitors workforce allocation and resources, and oversees project plans.
- In conjunction with division leadership, establishes long-term goals for department and adapts operational plans as changes occur.
- Creates visibility and support for utilization management and/or payment review programs. Develops resource materials and provides education and communication about programs to employees, providers and community stakeholders.
- Maintains clinical competency and keeps current on medical practices, procedures and industry trends.
- May develop and present educational updates to other departments.
- Oversees development and implementation of department programs. Responsible for program quality and successful outcomes of programs.
Duties performed primarily in an office environment.
Occasional off-site travel may be required.