Manager, Pre-Cert Operations

About the role

The Manager, Pre-Cert Operations is responsible for managing the execution of Quantum’s Pre-Certification delivery. This leader will have primary accountability for performance management, escalation triage and audit presentation.

Essential Responsibilities

• Provide direct leadership and subject matter expertise for frontline Pre-Certification nurses
• Ensure a focus on quality, consistency and member centricity
• Serves as a clinical subject matter expert for internal and external parties
• Continuously evaluate the staffing distribution and workload to ensure adequate balance. Adjust coverage as needed.
• Own development and performance management of frontline Nurses; maintain focus on key needs/expectations/initiatives
• Conducts routine 1 on 1 development meetings as well as check-in/performance review conversations with direct reports
• Lead the succession planning and IDP process for direct reports to ensure continued professional development
• Delivers performance feedback. Responsible for performance management and coaching support to develop the team and maximize success of employees
• Affixes day-to-day problem-solving, Q&A, and protocol guidance for staff
• Facilitate regular team discussions that reinforce key needs/expectations/initiatives, promote an awareness of program and staff performance, and provide a forum for Q&A
• Facilitate team huddles to ensure collaboration with workload and case needs
• Operational execution in alignment with strategic programmatic initiatives
• Support development, maintenance, and execution of processes, protocols, tools and systems that support program objectives
• Continuously monitor outcomes, address gaps and/or identify opportunities for greater programmatic impact, as needed
• Ensure compliance with relevant regulatory requirements
• Owner of both consultant and compliance audits through presentation of material, answering questions, and recapping themes needing addressed. Conducted in collaboration and partnership with Clinical Program, Clinical Delivery, and Pod leaders
• May support program leadership in development of new product capabilities or solutions
• Collaborate with UM Clinical Operations leadership on the continuous evaluation of processes/protocols and program effectiveness
• Implement process improvements and clinical initiatives to address identified needs as guided by program leadership
• Trend identification, root cause analysis, and development of corrective/preventative action plans within discipline/frontline delivery
• Available for client implementations, as need
• Escalation management and client-facing interaction to triage and address recurring issues
• All other duties as assigned

Qualifications

• Education: Bachelor’s or Master’s degree in nursing required
• Licenses/Certifications: Current and Active license as a Registered Nurse in the state of Ohio
• Minimum of 5 years of experience in clinical leadership with responsibility for direct management/oversight of a team preferred
• Minimum of 5 years of utilization management experience (pre-certification, concurrent review, and/or appeals)
• Experience utilizing standardized algorithms, policies and bulletins to guide determinations
• Experience collaborating with Medical Directors and senior-level clinical leaders to develop and continuously refine/review UM policy
• Knowledge of applicable regulatory standards and requirements
• Familiarity/experience with URAC Health Utilization Management standards preferred
• Proficient utilization of reporting tools and platforms for analyzing and synthesizing data to evaluate and guide performance
• Advanced strategic planning skills
• Proven success at identifying and selecting talent, and a passion for people development & coaching
• Strong administrative/technical skills; Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently
• A high degree of personal accountability and trustworthiness, a commitment to working within Quantum Health’s policies, values and ethics, and to protecting the sensitive data entrusted to us.