Supervisor, Utilization Review (TOC) - Hybrid

PURPOSE OF THE JOB

The Utilization Review Supervisor coordinates the activities of the UR department as they relate to medical necessity reviews, authorizations of inpatient, observation and sub-acute medical levels of care for Medicaid Business Segment members. This position monitors all authorization processes for meeting timeliness standards, cost effectiveness, and regulatory standards. Oversees the Transition of Care team ensuring members are contacted post hospital discharge within regulatory timeframes and member needs are met.

QUALIFICATIONS

• Required Work Experience: 2 years of direct clinical experience, 1 year of experience in utilization review

• Required Education: Associate’s Degree in general field of study

• Required Licenses: Active, current, and unrestricted license to practice in the State of Arizona as a Registered Nurse (RN)

• Preferred Qualifications: 1 year of managed care/health plan experience, 1 year of Medicaid and Medicare experience

• Preferred Education: Bachelor’s Degree in Nursing or related field of study

• Preferred Licenses: N/A

• Preferred Certifications: N/A

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

• Ensures inpatient authorization requests are completed accurately, thoroughly, and in a timely fashion to meet contractual requirements and ensures all reviews are conducted using InterQual.

• Evaluating statistics on department’s volumes, results, including approvals, denials, turnaround times for department and individual staff. Preparing and delivering reports to department and management staff.

• Performing audits of case files and staff’s work. Reviewing and updating department’s policies and desktop procedures.

• Manage day to day activity of assigned team. Directly supervises staff including participating in hiring, monitoring and evaluating performance, timecards, staff training.

• Completing IRR audits per policy; coach and mentor staff; work with management on employee performance issues. Monitor phone activity and staff productivity.

• Ensures team meets budget and performance goals. Participates in Quality Improvement Projects. Assists management and others in preparation for audits and other regulatory activities.

• Participates in interdepartmental meetings and trainings. Perform all other duties as assigned.

COMPETENCIES

• Required Job Skills: InterQual, Computer skills including MS Word, Excel spreadsheets, Communication skills: oral and written

• Required Professional Competencies: N/A

• Required Leadership Experience And Competencies: N/A

• Preferred Competencies: N/A

• Preferred Job Skills: N/A

• Preferred Professional Competencies: N/A

• Preferred Leadership Experience And Competencies: N/A

ON-SITE EXPECTATION AND FULL-TIME WORK SCHEDULE

The position has an onsite expectation of 2 days per week and requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.