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 expertise

Assist 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 timeframes

Interact with providers and staff to manage benefits aligned with state-based regulations, NCQA and/or URAC regulations, and CareSource policies

Review and revise workflows to maximize efficiencies

Monitor productivity and utilization trends

Oversee CQI activities and ensure audits and staff feedback occur at regular intervals

Regularly report all utilization management regulatory requirements

Ensure compliance with and reporting of all regulatory requirements

Maintain all utilization management reporting and trend data

Analyze under and over utilization information for impact on member quality of care and outcomes and formulate recommendations based on data

Develop, maintain and update all departmental policies and procedures; ensure notices of adverse action are provided in accordance with required regulations

Audit predetermination requests, cases for documentation and interrater reliability per CareSource policy

Act as liaison with other departments to assist with research and intervention

Perform 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 preferred

Minimum of five (5) years of clinical experience is required

Minimum of five (5) years of experience in one of the following is required: case management, utilization management, and/or quality improvement

Two years of utilization management experience is preferred

Managed care experience is preferred

Competencies, Knowledge and Skills:

Beginning Excel, Word and PowerPoint experience

Experience in data analysis and trending

Knowledge of utilization management standards and practices

Communication skills

Management and prior supervisory skills

Ability to work independently and within a team environment

Attention to detail

Familiarity of the health care field

Critical listening and thinking skills

Training/teaching skills

Strategic management skills

Negotiation skills/experience

Proper grammar usage

Change resiliency

Technical writing skills

Time management skills

Proper phone etiquette

Customer service oriented

Decision making/problem solving skills

Leadership 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

Compensation Range:
$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.

Compensation Type (hourly/salary):
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.
Brand=Commonwealth Care Alliance
Originally posted on Himalayas

Salary: USD 83,000 – 132,800 (annual)