Manager, Utilization Management

About the role

Manages prospective and concurrent Utilization Management (UM) programs including prior authorization, concurrent inpatient and continued stay reviews including authorization and management of selected post inpatient care. Reports to the Director of UM and coordinates with Case Management (CM) and Care Coordination (CC) Managers.

Responsibilities

• Provides leadership to ensure operational effectiveness and efficiency of prospective and concurrent UM including discharge planning activities to meet and exceed production and service-level goals.
• Provides coaching and oversight to staff to ensure staff success and development.
• Oversees the program quality assurance and quality improvement processes related to UM programs.
• Generates reports to identify trends and opportunities for process improvement.
• Facilitates efforts to enhance UM programs by working collaboratively with the UM Director and other Medical Management leaders to effectively manage contract and internal performance standards.
• Assists with Desk Procedures (DP) development, monitors and provides assistance with application use and training programs in support of DPs.
• Collaborates with Data Management staff for data compilation and statistical analysis regarding program outcomes.
• Develops audit reports to identify quality issues and to identify areas for enhanced staff training.
• Develops new training programs, training documents, and flow diagrams to address targeted operational issues.
• Collaborates with clinical leadership to implement new processes for enhancing service levels.
• Affords assistance with staffing projections for contract management and budgets.

Requirements

• Registered Nurse with current, unrestricted license for appropriate state (RN)
• 5 years’ experience in a clinical setting
• 2 year experience with a managed care program
• 3 years supervisory or management leadership experience in a healthcare environment
• Preferred Commercial Managed Care experience
• Master's Degree in Nursing or related field
• Veterans Healthcare or TRICARE Program experience
• Experience with policy development and technical writing
• Experience in budgeting, strategic program management and staff development

Qualifications

• Education: Bachelor's degree in Nursing or related field
• Experience: 7+ years of relevant experience

Skills

• Communication / People Skills
• Computer Literacy
• Delegation Skills
• Independent Thinking / Self-Initiative
• Information Management
• Leadership
• Multi-Tasking / Time Management
• Organizational Skills
• Team-Building / Team Player
• Technical Skills

Benefits

Comprehensive and progressive compensation and benefits package that includes:

• Medical, Dental and Vision Coverage
• Paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time

Pay

$113,000 - $119,000 per year

Schedule

Works non-regular hours, as required

Works remotely, with 10% travel

Company Overview

Taking Care of Our Nation’s Heroes. It’s Who We Are. It’s What We Do. Do you have a passion for serving those who served? Join the TriWest Healthcare Alliance Team! We’re On a Mission to Serve®!

We’re more than just a health care company. We’re passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more.