Manager

• 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.
• 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.
• Assists in the development and implementation of policies and procedures related to the Utilization Management processes.
• Ensures that utilization management interventions are collaborative and focus on maximizing quality member health care outcomes.
• 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.
• Oversees the education on utilization management that is provided to internal and external stakeholders and partners to continuously improve processes and build network relationships.
• 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.
• Educates team members on the data that is collected within the position and facilitate improvement in outcomes within the team.
• Assists with monitoring performance standards, productivity and ensuring staff coverage to meet the needs of the department.
• Formulates, implements and evaluates educational strategies for staff.
• Maintains a working knowledge of the requirements of regulatory and compliance entities.
• When needed, fill in for staff members to ensure that the operations of the utilization management team are never compromised.
• Commits to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Management.
• Provides clinical, procedural or interpretational assistance.
• Ability to present complex ideas and data to a wide variety of stakeholders from frontline employees to executive c-suite.
• Other duties as assigned or requested.

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