Supervisor, Utilization Management

About the role

Supervises daily Utilization Management (UM) program operations. This position reports to a Manager of Utilization Management in either Prospective, Retrospective, or Appeals and Reconsideration for the TRICARE contract. The supervisor coordinates across teams to support meeting contractual metrics and timeliness, standardized clinical care requirements and accreditation standards. This position is responsible for supervision of UM performance and staff management. Development and preparation of operational reports. Functions as backup for staff during high volume periods.

Responsibilities

• Supervises day to day UM operations to ensure operational effectiveness and efficiency.
• Ensures staff is fully-informed of changes by communicating updates, policy revisions, performance outcomes, and significant events.
• Prepares work schedules and monitors staff caseloads to ensure adequate staffing levels at all times and accurate data entry and application of the medical management system.
• Makes sure staff adheres to established criteria, including InterQyal, internally developed guidelines, decision support tools, contract requirements and TriWest policies and desk procedures.
• Prepares reports for tracking and trending of UM activities. Interprets reports and identifies UM opportunities to share with management.
• Maintains the UM process and identifies and implements process improvements to ensure program quality assurance and compliance. Reports Potential Quality Issues (PQI).
• Responsible for interviewing and hiring new staff. Provides coaching and oversight to staff to ensure staff success and development. Assists with implementation, orientation and training of new staff.
• Aids in the development of desk procedures, processes, workflow changes, and reports. Systematically evaluates the quality and effectiveness of staff performance. Advises and coaches when appropriate and completes annual performance appraisals.
• Participates in meetings as required. Collaborates across the clinical operations team for enhancing service levels. Coordinates activities with contracted partners to meet Utilization Management (UM) Plan goals. Completes special projects.

Requirements

• Registered Nurse, with current valid, unrestricted nursing license
• 3+ years of job related experience in a healthcare environment
• 3+ years supervisory or leadership experience in a healthcare environment
• 2+ years utilization review or case management
• CCM or HCQM certification
• Knowledge of government health care programs
• Familiarity with utilization review criteria
• Knowledge of medical billing and coding
• Prior experience with remote work environments

Preferred

• Medical/Surgical or Behavioral Health experience
• Commercial Managed Care experience

Skills

• Coaching / Training / Mentoring
• Communication / People Skills
• Computer Literacy
• Coping / Flexibility
• Delegation Skills
• Independent Thinking / Self-Initiative
• Information Management
• Leadership
• Multi-Tasking / Time Management
• Organizational Skills
• Problem Solving / Analysis
• Team-Building / Team Player
• Technical Skills

Benefits

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. Of course, we also offer a 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

$101,000 - $107,000 per year

Schedule

Works non-regular hours, as required. Works remotely, with up to 10% travel. Ability to meet mandatory contract compliance timelines.

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®! Our job is to make sure that America’s heroes get connected to health care in the community. At TriWest Healthcare Alliance, we’ve proudly been on that important mission since 1996.

Equal Employment Opportunity

TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.