Manager, Utilization Management

POSITION SUMMARY:

The Manager of Utilization Management (UM) is a Registered Nurse (RN) who is responsible for all aspects of compliance related to utilization management and prior authorization across the continuum of care. Directly responsible for the supervision of the Utilization Management Nurses and Referral Coordinators in the Medical Management department.

The position works closely with the Director of Medical Management, Chief Medical Officer, Medical Directors and/or Physician Advisors on clinical issues/clinical review and interfacing with external agencies and CCP's contracted partners in care vendors.

The Manager of Utilization Management is further responsible to ensure all functions are operating in accordance with the organization's mission, values and strategic goals, are focused on continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of CCP's culturally diverse membership.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Duties include gathering, analyzing and reporting utilization management (UM) data, acting as a resource on prior authorization issues, and coordinating all aspects of the utilization management/prior authorization.

• Ensure appropriate usage of resources in order to facilitate the UM process and compliance within applicable state program guidelines and other contractual guidelines.

• Assist with ensuring consistent data collection from UM staff that is used to assist the company in achieving company goals, to improve monitoring and reporting in order to meet contractual requirements. Identify opportunities for process improvements necessary to facilitate department functions.

• Educates staff as necessary to ensure consistent performance and adherence to standards

• Assist the Director of Medical Management with coordinating and facilitating system processes with providers, partners in care, and subcontractors as necessary.

• Monitor daily operations of the UM Department prior authorization process

• Ensure that nurses are working prior authorization request within the department timeframes.

• Reviews (or delegates the review of) all denial letters prior to issuing them to member and provider.

• Ensures letters of agreements (LOA) process is being followed appropriately.

• Keeps aware and trains staff of updates to the software operating systems and any upgrades that occur.

• Responds to staff questions and assists with problems encountered daily.

• Monitors prior authorization fax queues to ensure faxes are worked timely and turnaround times (TAT) are met.

• Compile and review multiple reports on work function activities for statistical and financial tracking purposes to identify utilization trends and make recommendations to management.

• Assists in department management

• Monitors attendance and performs employee evaluations

• Produce and review reconciliation (audit) reports and identify inconsistencies with established department processes.

• Responsible for employee training of all Medical Management's policy and procedures.

• Demonstrates knowledge and understanding of all product lines.

• Ensure compliance with office policies and procedures.

• Review, evaluate and recommend improvements in 01 process practices for accuracy and validity.

• Develop staff skills and competencies through training and experience.

• Maintains a high degree of professionalism.

• Demonstrates the ability to make decisions, take appropriate action and follow tasks through to completion.

• Recognizes and analyzes the implications of new situations and develops workable solutions.

• Acts as a role model in demonstrating the customer service standards of the organization.

• Responds cooperatively to Managers and staff members in other departments to promote teamwork.

• Ensures that appearance and personal conduct are always professional.

• Works at maintaining a good rapport and a cooperative working relationship with staff, internal and external customers.

• Represents the organization in a positive and professional manner in the community.

• Always maintains organizational confidentiality.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

SKILLS AND ABILITIES:

• Excellent written and verbal communication skills.

• Must be organized and a self-starter.

• Ability to work in a fast paced, stressful environment with changing priorities.

• Work independently with decision making skills.

Work Schedule:

As a continued effort to provide a safe and productive work environment, Community Care Plan is currently following a hybrid work schedule. Staff are able to work from home 3 days a week and will report to the office 2 days a week.

*The company reserves the right to change the work schedules based on the company needs.

PHYSICAL DEMANDS:

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. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating and preserving a culture of diversity, equity and inclusion.

Qualifications

• Unrestricted Florida RN Licensure

• CCM or UM Certification preferred.

• BSN is preferred.

• Five (5) years managed care experience in an HMO environment preferred, must have supervisory experience in a healthcare environment.

• Knowledge of Medicaid and Medicare guidelines and InterQual Criteria.

• Knowledge of Medicaid and Medicare benefits.

• Understanding of review process and administration of benefits.