Resp & Qualifications PURPOSE: The Supervisor, Utilization Management supervises the daily operations of the Utilization Management (UM) department to ensure the appropriate coordination of health care services and compliance with Utilization Review (UR) policies and procedures, as well as, regulatory and CareFirst's accreditation standards. We are looking for an experienced professional in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.
ESSENTIAL FUNCTIONS:- Supervises the daily operations of UM staff. Recruits, retains and develops a high performing team. Evaluates performance of each team member, generates development plans and sets goals within the context of the corporate policies and procedures. Ensures appropriate usage of resources in order to facilitate the UM process. Educates staff as necessary to ensure consistent performance and adherence to standards.
- Ensures compliance within applicable state program guidelines. Evaluates compliance policies and procedures and analyzes/recommends enhancements.
- Facilitates the collection and validation of data from UM staff to ensure consistency and accuracy. Assists in analyzing and reporting data used to support the achievement of corporate objectives, enhance operational monitoring and meet external reporting requirements.
- Evaluates departmental processes and recommends improvement opportunities to enhance operational efficiency and support departmental objectives.
- Provides timely communication to management regarding department operations including customer and case-related issues, operational trends, variances, reporting outcomes, action plans, etc., to support informed decision-making.
SUPERVISORY RESPONSIBILITY:This position manages people.
QUALIFICATIONS:Education Level: Bachelor's Degree in Nursing OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Experience: 3 years Medical/surgical experience including, but not limited to, inpatient care, outpatient/home care and hospice care, and experience reviewing patient medical care with demonstrated leadership.
Licenses/Certifications Required Upon Hire:RN - Registered Nurse - State Licensure And/or Compact State Licensure
Knowledge, Skills and Abilities (KSAs)- Excellent analytical, problem-solving skills with ability to judge appropriateness of member services and treatments on a case by case basis.
- Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility.
- Knowledge of accreditation standards and federal/state regulations and general principles relating to utilization review.
- Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues.
- Computer skills, including Microsoft Office programs.
- Ability to mentor and coach associates to accomplish goals, provide objective evaluation of associate performance, and implement strategies to improve individual and team-based performance as needed.
Travel Requirements:
5% Able to travel to CareFirst sites for meetings and off site Health Services meetings
Salary Range: $82,800 - $170,775
Salary Range Disclaimer The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
PHYSICAL DEMANDS:The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
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