Manager, Utilization Management RN - Peak Health

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).

EXPERIENCE:

1. Five (5) years of healthcare clinical experience.

2. Three (3) years of managed care experience with progressive clinical responsibilities in a managed care organization for Commercial, Medicare, and/or Medicaid products.

3. Three (3) years of Health Plan Utilization Management experience.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor of Science in Nursing (BSN).

EXPERIENCE:

1. Three (3) years Utilization Management for Commercial, Medicare and/or Medicaid populations.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Oversees the build and Implement utilization management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews) that are consistent with established industry and regulatory standards/guidance.

2. Manages the build and implement all utilization management reviews according to accepted and established criteria, as well as other clinical and regulatory guidelines and policies.

3. Assists in the development and implementation of policies and procedures related to the Utilization Management processes.

4. Ensures that utilization management interventions are collaborative and focus on maximizing quality member health care outcomes.

5. Supervises the facilitation of the Peer-to-Peer Review process, and work with the Medical Directors to continuously improve member and Provider Network services for this process.

6. Oversees the education on utilization management that is provided to internal and external stakeholders and partners to continuously improve processes and build network relationships.

7. Facilitates a collaborative environment that focuses on collaboration with other members of the medical management team to identify members whose healthcare outcomes may be enhanced by coaching and/or case management interventions.

8. Educates team members on the data that is collected within the position and facilitate improvement in outcomes within the team.

9. Assists with monitoring performance standards, productivity and ensuring staff coverage to meet the needs of the department.

10. Formulates, implements and evaluates educational strategies for staff.

11. Maintains a working knowledge of the requirements of regulatory and compliance entities.

12. When needed, fill in for staff members to ensure that the operations of the utilization management team are never compromised.

13. Commits to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Management.

14. Provides clinical, procedural or interpretational assistance.

15. Ability to present complex ideas and data to a wide variety of stakeholders from frontline employees to executive c-suite.

16. Other duties as assigned or requested.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Ability to stand and walk short distances for eight or more hours.

2. Frequent bending, stooping, or stretching.

3. Ability to lift 30 pounds and push 50 pounds.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment.

SKILLS AND ABILITIES:

1. Working Knowledge of InterQual and/or Milliman Care Guidelines.

2. Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning.

3. Excellent written and oral communication.

4. Problem solving capabilities to drive improved efficiencies and customer satisfaction.

5. Attention to detail.

6. Proficiency with Microsoft Office.

7. Ability to work under stressful working conditions.

8. Meeting defined deadlines and deliverables is an imperative skill for this role.

Additional Job Description:

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).

EXPERIENCE:

1. Five (5) years of healthcare clinical experience.

2. Three (3) years of managed care experience with progressive clinical responsibilities in a managed care organization for Commercial, Medicare, and/or Medicaid products.

3. Three (3) years of Health Plan Utilization Management experience.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor of Science in Nursing (BSN).

EXPERIENCE:

1. Three (3) years Utilization Management for Commercial, Medicare and/or Medicaid populations.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Oversees the build and Implement utilization management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews) that are consistent with established industry and regulatory standards/guidance.

2. Manages the build and implement all utilization management reviews according to accepted and established criteria, as well as other clinical and regulatory guidelines and policies.

3. Assists in the development and implementation of policies and procedures related to the Utilization Management processes.

4. Ensures that utilization management interventions are collaborative and focus on maximizing quality member health care outcomes.

5. Supervises the facilitation of the Peer-to-Peer Review process, and work with the Medical Directors to continuously improve member and Provider Network services for this process.

6. Oversees the education on utilization management that is provided to internal and external stakeholders and partners to continuously improve processes and build network relationships.

7. Facilitates a collaborative environment that focuses on collaboration with other members of the medical management team to identify members whose healthcare outcomes may be enhanced by coaching and/or case management interventions.

8. Educates team members on the data that is collected within the position and facilitate improvement in outcomes within the team.

9. Assists with monitoring performance standards, productivity and ensuring staff coverage to meet the needs of the department.

10. Formulates, implements and evaluates educational strategies for staff.

11. Maintains a working knowledge of the requirements of regulatory and compliance entities.

12. When needed, fill in for staff members to ensure that the operations of the utilization management team are never compromised.

13. Commits to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Management.

14. Provides clinical, procedural or interpretational assistance.

15. Ability to present complex ideas and data to a wide variety of stakeholders from frontline employees to executive c-suite.

16. Other duties as assigned or requested.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Ability to stand and walk short distances for eight or more hours.

2. Frequent bending, stooping, or stretching.

3. Ability to lift 30 pounds and push 50 pounds.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment.

SKILLS AND ABILITIES:

1. Working Knowledge of InterQual and/or Milliman Care Guidelines.

2. Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning.

3. Excellent written and oral communication.

4. Problem solving capabilities to drive improved efficiencies and customer satisfaction.

5. Attention to detail.

6. Proficiency with Microsoft Office.

7. Ability to work under stressful working conditions.

8. Meeting defined deadlines and deliverables is an imperative skill for this role.

HYBRID (Morgantown, WV)

• Previous health plan utilization management experience
• Unencumbered RN licensure required (WV, compact - or willing to obtain upon hire)
• Weekend coverage as needed

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

Company:

Cost Center: