Hybrid Manager, Utilization Management, RN

at Peak Health

• Job title: Manager, Utilization Management, RN
• Job type: Full Time
• Experience level: Mid level, Senior
• Salary: Not specified
• Degree requirement: Bachelor's Degree
• Tech skills: Realm
• Location requirements: Hybrid, Morgantown, United States

About the role

• Manager of Utilization Management overseeing department operations and driving effective health utilization at Peak Health. Collaborating with medical directors and ensuring quality outcomes for members.

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).
• Three (3) years Utilization Management for Commercial, Medicare and/or Medicaid populations.
• 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.
• Excellent written and oral communication.
• Proficiency with Microsoft Office.

Benefits

• Welcome! We’re excited you’re considering an opportunity with us!