Position Purpose: Perform duties to conduct and manage the day to day operations of theutilization management function. Communicate with staff to facilitate daily department functions.
- Review analyses of activities, costs, operations and forecast data to determine progress toward stated goals and objectives.
- Promote compliance with federal and state regulations and contractual agreements.
- Develop, implement and maintain compliance, policies and procedures regarding medical utilization management functions.
- Develop, implement, and maintain utilization management programs to facilitate the use of appropriate medical resources and decrease the business unit's financial exposure.
- Compile and review multiple reports on work function activities for statistical and financial tracking purposes to identify utilization trends and make recommendations to management.
- Facilitate on-going communication between utilization management staff and contracted providers.
- Develop staff skills and competencies through training and experience. Available to non-clinical staff as a resource for clinical questions.
Education/Experience: Bachelor’s degree in related field or equivalent experience. 3+ years utilization management and recent experience in a clinical setting. Utilization management and dental records revision experience required. Familiarity with Medicare and Medicaid managed care practices and policies, CHIP and SCHIP. Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.
License/Certification: Possess an active, professional and unrestricted license as a Licensed Dental Hygienist to practice as a health professional in a state or territory of the United States. The license has a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review. Case Management Certification preferred.