Assistant Manager, Medical Management
Community Health Options
full-time
Posted on:
Location Type: Remote
Location: Remote • Maine • 🇺🇸 United States
Visit company websiteJob Level
JuniorMid-Level
About the role
- 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
Requirements
- Bachelor's or Associate's Degree in Nursing
- Active and unrestricted Compact or Maine clinical license
- Minimum of 2-3 years of Health Plan Medical Management experience
- Leadership experience with working knowledge of human resource principles
- Strong working knowledge of nationally recognized clinical standards of care (e.g., MCG)
- Experience with utilization management, care management, complex case management, care coordination, and claims processing
- Knowledge of cost containment strategies and benefit design
- Familiarity with NCQA standards, State and Federal regulations
- Advanced skills in Microsoft Products and adaptability to electronic documentation systems
- Excellent communication, writing, analytical and problem-solving skills
- Ability to adapt and problem-solve complex, multifaceted, and emotionally charged situations
Benefits
- Work from home flexibility based on operational need and supervisor approval
- Flexible schedules to accommodate varying needs of our people
- Professional development opportunities and access to training
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
Utilization ManagementCare ManagementClinical Claims ReviewCost Containment StrategiesBenefit DesignComplex Case ManagementCare CoordinationClaims ProcessingClinical Standards of CarePopulation Utilization Trends
Soft skills
LeadershipMentoringCoachingCommunicationAnalytical SkillsProblem-SolvingCollaborationAdaptabilityInterpersonal SkillsProfessional Development
Certifications
Bachelor's Degree in NursingAssociate's Degree in NursingActive Clinical License