Job Summary:The Manager, Utilization Management is responsible for the oversight of all utilization management activities ensuring consistency of services and achievement of utilization targets.
Essential Functions:- Assist in coordination and management of the pre-determination process of medical and dental services; ensure the consistent application of criteria for authorization decision, and that decisions to deny or reduce services are made by a health care professional who has appropriate clinical expertise
- Assist in the development of integrated service delivery to members and oversee utilization management data and processes to maintain industry standards and practices including decisions within allowable timeframes
- Interact with providers and staff to manage benefits aligned with state-based regulations, NCQA and/or URAC regulations, and CareSource policies
- Review and revise workflows to maximize efficiencies
- Monitor productivity and utilization trends
- Oversee CQI activities and ensure audits and staff feedback occur at regular intervals
- Regularly report all utilization management regulatory requirements
- Ensure compliance with and reporting of all regulatory requirements
- Maintain all utilization management reporting and trend data
- Analyze under and over utilization information for impact on member quality of care and outcomes and formulate recommendations based on data
- Develop, maintain and update all departmental policies and procedures; ensure notices of adverse action are provided in accordance with required regulations
- Audit predetermination requests, cases for documentation and interrater reliability per CareSource policy
- Act as liaison with other departments to assist with research and intervention
- Perform any other job related instructions, as requested
Education and Experience:- Associate's Degree in Nursing is required and Bachelors of Science in Nursing (BSN) is preferred
- Minimum of five (5) years of clinical experience is required
- Minimum of five (5) years of experience in one of the following is required: case management, utilization management, and/or quality improvement
- Two years of utilization management experience is preferred
- Managed care experience is preferred
Competencies, Knowledge and Skills:- Beginning Excel, Word and PowerPoint experience
- Experience in data analysis and trending
- Knowledge of utilization management standards and practices
- Communication skills
- Management and prior supervisory skills
- Ability to work independently and within a team environment
- Attention to detail
- Familiarity of the health care field
- Critical listening and thinking skills
- Training/teaching skills
- Strategic management skills
- Negotiation skills/experience
- Proper grammar usage
- Change resiliency
- Technical writing skills
- Time management skills
- Proper phone etiquette
- Customer service oriented
- Decision making/problem solving skills
- Leadership experience and skills
Licensure and Certification:- Current, unrestricted licensure in state of practice as a Registered Nurse (RN) is required
Working Conditions:- General office environment; may be required to sit or stand for extended periods of time
Compensation Range:$83,000.00 - $132,800.00
CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):Salary
Organization Level Competencies- Fostering a Collaborative Workplace Culture
- Cultivate Partnerships
- Develop Self and Others
- Drive Execution
- Influence Others
- Pursue Personal Excellence
- Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time.#LI-JS2
Brand=Commonwealth Care Alliance
