Business Manager – Military Division
Acosta
Manager, Utilization Management, RN
Peak Health
full-time
Posted on:
Location Type: Hybrid
Location: Morgantown • Virginia, West Virginia • 🇺🇸 United States
Visit company websiteJob Level
Mid-LevelSenior
Tech Stack
Realm
About the role
- 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.
Requirements
- 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).
- Five (5) years of healthcare clinical experience.
- Three (3) years of managed care experience with progressive clinical responsibilities in a managed care organization for Commercial, Medicare, and/or Medicaid products.
- Three (3) years of Health Plan Utilization Management experience.
- Bachelor of Science in Nursing (BSN).
- Three (3) years Utilization Management for Commercial, Medicare and/or Medicaid populations.
- Working Knowledge of InterQual and/or Milliman Care Guidelines.
- Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning.
- Excellent written and oral communication.
- Proficiency with Microsoft Office.
Benefits
- Welcome! We’re excited you’re considering an opportunity with us!
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
utilization managementclinical experiencemanaged care experienceHealth Plan Utilization ManagementInterQualMilliman Care Guidelinesdisease managementcase managementdischarge planning
Soft skills
collaborationcommunicationleadershipeducationteamworkproblem-solvingperformance monitoringcontinuous improvementpresentation skills
Certifications
Registered Nurse licenseBachelor of Science in Nursing (BSN)
