Manager, Utilization Management

Metadata: Monday–Friday, 8:00 AM–5:00 PM, 40 hours per week.

About the role

Oversee the day-to-day operation of the clinical staff for Medical Utilization Management across all lines of business. Ensure proper staffing levels, work assignments, and performance evaluations. Serve as a subject-matter expert on benefits, policies, and operational procedures within your line of business, and ensure all medical operations align with The Health Plan’s policies and procedures.

Responsibilities

• Orient new staff to department policies, procedures, and system functions.
• Identify appropriate staffing levels and assignments.
• Monitor performance criteria for staff members.
• Assist the Director in implementing departmental plans, programs, and related reporting.
• Review utilization performance against established goals and implement changes to drive continual improvement.
• Perform routine inter-rater monitoring on nurse navigators and support staff to ensure service quality.
• Review utilization management functions, including pre-authorization and inpatient navigation, to affect continual improvement.
• Interpret benefits, laws, policies, procedures, and objectives; ensure compliance with all requirements.
• Share responsibility with the Director for collecting, analyzing, evaluating, and presenting clinical management and operational data to various audiences.
• Assist the Director in developing, implementing, and evaluating the yearly work plan.
• Participate on assigned committees.
• Conduct performance evaluations of nurse navigators.
• Collaborate with the Director to develop mechanisms for staff development and keep current with new regulations, policies, and trends.
• Maintain skills to provide coverage for utilization management during staff shortages or as needed.
• Identify and report potential high-cost cases to the reinsurance carrier using hospital reviews, prior authorization requests, or claims cost reports.
• Conduct clinical audits and provide necessary feedback.
• Participate in activities related to regulatory functions as directed by the Manager of Clinical Compliance and/or Director (e.g., CMS, BMS, Qlarent, NCQA, and other regulatory bodies across all lines of business).

Requirements

• Active Ohio or West Virginia multistate Registered Nurse (RN) licensure, which must be maintained throughout employment, including compliance with State Boards of Nursing continuing education policy.
• Additional licensure in other states as company expansion warrants.
• Minimum of five (5) years of nursing experience, with critical care or other acute care experience required.
• Experience with care coordination, discharge planning, clinical documentation, and utilization review.
• Knowledge of InterQual criteria and patient status changes.
• Strong communication and leadership skills.
• Knowledge of accreditation standards, federal and state regulations.
• Considerable knowledge of clinical service UM policies and procedures.
• Ability to analyze data and employ approved management techniques and statistical tools to maximize effectiveness, efficiency, and information.
• Ability to interpret established policies into operating procedures and execute complex case navigation programs.
• Ability to coordinate various functions and activities for maximum cooperation and efficiency.
• Ability to direct, instruct, and advise staff in approved methods, procedures, and practices for effective utilization management.
• Ability to receive and effectively address day-to-day problems presented by staff and others.
• Effective organizational, oral, and written communication skills; problem-solving, program development, and computer skills.
• Strong leadership and team-building skills.
• Ability to work with a variety of disciplines and levels of staff across departments.
• Ability to establish priorities, meet deadlines, and manage the department’s productivity.
• Ability to form positive, collaborative relationships with members of the management team.

Preferred Qualifications

• Certification in managed care, case management, or a related clinical certification.
• Utilization Management, Quality Improvement, or Disease Management experience.
• Active licensure in additional states as requested.