Wundmanager providing professional care for chronic and difficult - to - heal wounds in a specialized home care setting. Joining a dynamic team with a focus on improving patient quality of life.
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
Wundmanager providing professional care for chronic and hard - to - heal wounds in a specialized nursing service. Collaborating with patients and families while maintaining compliance with healthcare regulations.
Wundmanager providing professional care for chronic and difficult - to - heal wounds. Collaborating with multidisciplinary teams to ensure optimal patient care in home settings.
Wundmanager providing specialized care for chronic wounds and managing patient documentation in Germany. Collaborating closely with patients' families and other healthcare providers for optimal care.
Wundmanager providing professional care for chronic wounds at WundCura GmbH. Supporting patients through consultation, documentation, and collaboration with care teams in Dortmund, Germany.
Wundmanager (m/w/d) providing specialized wound care in patients’ homes for a dynamic healthcare provider. Responsible for patient education and collaboration with care teams.
Wundmanager providing professional wound care in patient homes for WundCura GmbH. Involve in patient training, collaboration, and ensure regulatory compliance while managing existing accounts.
Forecasting Manager analyzing market trends and developing sales forecasts for GSK's General Medicines unit. Collaborating with various stakeholders to present forecasts and insights driving business decisions.
Client Delivery Manager overseeing onboarding and integration for FINBOURNE's SaaS solutions in financial services. Managing complex projects and stakeholder relationships to ensure successful client engagements.
Category Business Manager defining go - to - market strategies for IT solutions at Ingram Micro. Cultivating vendor relationships and driving business growth in a hybrid work environment.