Manager, Utilization Management - Must have a MA RN License

Job Summary The Manager, Utilization Management is responsible for the oversight of all utilization management activities ensuring consistency of services and achievement of utilization targets. Essential Functions Assist in coordination and management of the pre-determination process of medical and dental services; ensure the consistent application of criteria for authorization decision, and that decisions to deny or reduce services are made by a health care professional who has appropriate clinical expertiseAssist in the development of integrated service delivery to members and oversee utilization management data and processes to maintain industry standards and practices including decisions within allowable timeframesInteract with providers and staff to manage benefits aligned with state-based regulations, NCQA and/or URAC regulations, and CareSource policiesReview and revise workflows to maximize efficienciesMonitor productivity and utilization trendsOversee CQI activities and ensure audits and staff feedback occur at regular intervalsRegularly report all utilization management regulatory requirementsEnsure compliance with and reporting of all regulatory requirementsMaintain all utilization management reporting and trend dataAnalyze under and over utilization information for impact on member quality of care and outcomes and formulate recommendations based on dataDevelop, maintain and update all departmental policies and procedures; ensure notices of adverse action are provided in accordance with required regulationsAudit predetermination requests, cases for documentation and interrater reliability per CareSource policyAct as liaison with other departments to assist with research and interventionPerform any other job related instructions, as requested Education And Experience Associate’s Degree in Nursing is required and Bachelors of Science in Nursing (BSN) is preferredMinimum of five (5) years of clinical experience is requiredMinimum of five (5) years of experience in one of the following is required: case management, utilization management, and/or quality improvementTwo years of utilization management experience is preferredManaged care experience is preferred Competencies, Knowledge And Skills Beginning Excel, Word and PowerPoint experienceExperience in data analysis and trendingKnowledge of utilization management standards and practicesCommunication skillsManagement and prior supervisory skillsAbility to work independently and within a team environmentAttention to detailFamiliarity of the health care fieldCritical listening and thinking skillsTraining/teaching skillsStrategic management skillsNegotiation skills/experienceProper grammar usageChange resiliencyTechnical writing skillsTime management skillsProper phone etiquetteCustomer service orientedDecision making/problem solving skillsLeadership experience and skills Licensure And Certification Current, unrestricted licensure in state of practice as a Registered Nurse (RN) is required Working Conditions General office environment; may be required to sit or stand for extended periods of time $83,000.00 - $132,800.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Salary Organization Level Competencies - Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.