Store Manager responsible for day - to - day operations at Coles Supermarkets. Achieving commercial targets and providing exceptional customer service in a fast - paced environment.
About the role
- Manager of Utilization Management overseeing health plan operations and team collaboration with medical directors. Responsible for driving quality outcomes and process improvements in utilization management.
Responsibilities
- Oversees the build and Implement utilization management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews) that are consistent with established industry and regulatory standards/guidance.
- Manages the build and implement all utilization management reviews according to accepted and established criteria, as well as other clinical and regulatory guidelines and policies.
- Assists in the development and implementation of policies and procedures related to the utilization management processes.
- Ensures that utilization management interventions are collaborative and focus on maximizing quality member health care outcomes.
- Supervises the facilitation of the Peer-to-Peer Review process, and work with the Medical Directors to continuously improve member and Provider Network services for this process.
- Oversees the education on utilization management that is provided to internal and external stakeholders and partners to continuously improve processes and build network relationships.
- Facilitates a collaborative environment that focuses on collaboration with other members of the medical management team to identify members whose healthcare outcomes may be enhanced by coaching and/or case management interventions.
- Educates team members on the data that is collected within the position and facilitate improvement in outcomes within the team.
- Assists with monitoring performance standards, productivity and ensuring staff coverage to meet the needs of the department.
- Formulates, implements and evaluates educational strategies for staff.
- Maintains a working knowledge of the requirements of regulatory and compliance entities.
- When needed, fill in for staff members to ensure that the operations of the utilization management team are never compromised.
- Commits to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Management.
- Provides clinical, procedural or interpretational assistance.
- Ability to present complex ideas and data to a wide variety of stakeholders from frontline employees to executive c-suite.
- Other duties as assigned or requested.
Requirements
- Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
- Five (5) years of healthcare clinical experience.
- Three (3) years of managed care experience with progressive clinical responsibilities in a managed care organization for Commercial, Medicare, and/or Medicaid products.
- Three (3) years of Health Plan Utilization Management experience.
- Bachelor of Science in Nursing (BSN) (Preferred).
- Three (3) years Utilization Management for Commercial, Medicare and/or Medicaid populations (Preferred).
- Working Knowledge of InterQual and/or Milliman Care Guidelines.
- Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning.
- Proficiency with Microsoft Office.
Benefits
- Weekend coverage as needed
- Exempt/Non-Exempt: United States of America (Exempt)
Job title
Job type
Experience level
Salary
Not specified
Degree requirement
Tech skills
Location requirements
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