Community Health Options

Manager

• Provide day-to-day operational leadership for Utilization Management (UM) and Care Management (CM)
• Lead an interdisciplinary team to provide integrated medical and behavioral healthcare
• Ensure adherence to NCQA standards and applicable State and Federal regulations
• Maintain strong working knowledge of Health Plan benefits and network design and facilitate clinical claims review based on Member eligibility, benefit coverage and medical necessity
• Support oversight of referrals, timely completion of work, and tracking services to promote high-quality, cost-effective care
• Navigate complex clinical presentations leveraging care management and utilization management principles
• Participate in quality improvement initiatives and review population utilization trends to identify outliers
• Compile reports for NCQA, regulators, compliance, auditors, and applicable committees
• Develop and maintain super user expertise of documentation platform and reporting tools
• Monitor team performance, provide mentoring and coaching, and facilitate professional development opportunities
• Collaborate with internal stakeholders to promote exemplary Member and Provider customer service

Assistant Manager, Medical Management