Maintains accountability for medical management functions to achieve the business and clinical outcomes for the health plan, meeting contract requirements, National Committee of Quality Assurance (NCQA) accreditation standards, and supporting initiatives with providers and members to manage cost of care. Oversees utilization management and criteria-based reviews of care, clinical appeals regarding medical necessity, and the interaction with claims payment policies and processes. Also oversees the health plan's 24/7 Nurse Line program and the clinical management of crisis calls.
-Directs, coordinates and evaluates efficiency and productivity of utilization management functions.. Works closely with pharmacy and vendors to assure integration, oversight, and efficiency of utilization management and appeals processes and for delegated functions. In collaboration with the national clinical team, assures that all utilization management-related activities meet the standards required for the state contract and NCQA.
-Leads and organizes the ongoing evaluation of the utilization management program against quality and utilization benchmarks and targets. Identifies opportunities for improvement; organizes and manages cost of care initiatives. Collaborates with local and national leaders including Quality Improvement, Analytics, Finance, Network, and other areas to assure a comprehensive approach to managing quality of care, service, and cost of care. Provides expert input to Finance regarding patterns of utilization and cost and high cost cases.
-Assures staff selection, training, and evaluation to promote the development of a high quality team and effective transitions of care with the clinical care teams.
-Works closely with and provides input to national health plan clinical team on program design, policies, procedures, workflows, and correspondence.
-Collaborates with Network leaders to design and implement successful methods for working with hospitals, home health, and other services providers. Ensures integration and efficiency of Network strategy and vendor relationships with utilization management and claims processes. Works closely with network on the training and evaluation of providers as well in resolving provider related issues.
-Directs staff who assure quality, inter-rater reliability and standards are met in daily operations. Responsible for resolution and communication of utilization management issues and concerns and corrective action plan activities and reporting.
-Participate as a member of health plan Quality Insurance Committee and co-chair health plan Utilization Management Committee.
Bachelors (Required), Masters
License and Certifications - Required
RN -Registered Nurse, State and/or Compact State Licensure - Care Mgmt
License and Certifications - Preferred
Other Job Requirements
-Must have experience overseeing contractual performance standards. -Minimum 7 years direct supervisory experience.-Minimum 5 years in utilization management operations.-Experience with reporting and analyzing managed care utilization data.