Manager Utilization Management Review--Managed Care

Amerihealth Caritas Health Plan Raleigh , NC 27611

Posted 1 week ago


  • Direct activities of the Utilization Management staff. Oversee staff performance with regard to prior authorization, medical necessity determinations, concurrent review, retrospective review, continuity of care, care coordination, and other clinical and medical management programs. These responsibilities extend to physical and behavioral health care and transportation services.

  • Ensure effective daily operation of the Utilization Management Department utilizing all applicable statutory provisions, contracts and established policies and administrative procedures.

  • Maintain optimal staffing patterns based on contractual obligations and current Utilization Management budget. Comply with all policies and procedures for personnel requisitions, interviews and employment. Maintain accurate position control and organizational chats of assigned departments..

  • Partake in internal pharmacy therapeutic committee and work closely with the Directors of Pharmacy, pharmacy benefits manager (PBM), and the State's PBM team.

  • Prepare reports and conduct analysis of operations / services as required by departmental, corporate, regulatory, and State requirements. Work collaboratively with Information Services Department on identifying required data for reporting.

  • Assist in preparation, coordination, and follow up of Utilization Management audits, such as readiness review and site visits, pertaining to the Utilization Management Department.

  • Partner with community agencies and contracted vendors to develop and maintain collaborative contact to assure members have access to the appropriate resources and to avoid duplication of efforts.

  • Act as a liaison with outside entities, including but not limited to physicians, hospital, health care vendors. social services agencies, member advocates, and other entities.

  • Participate in coordination of internal and external Provider and Member directed communication regarding issues impacting Utilization Management coordination and delivery, such as medication management, use of generic medications, etc.

  • Establish performance and productivity requirements and communicate expectations to management team. Work collaboratively with Supervisor in identification of individual and / or group deficiencies in scheduled Performances Reviews. Establish action plan for assessment and resolution of identified issues.

  • Oversee the collaborative efforts of the Supervisors to ensure that all new and existing staff are oriented to organizational and department policies and procedures. Ensure that credentials of all licensed staff are verified in accordance with licensing agency initially and prior to expiration date. Maintain current and accurate files of such licensure and ongoing education status. Ensure that staff meets minimal skill and clinical knowledge requirements to be successful in assigned role.

  • Participate in current process review and development of new and / or revised work processes, policies and procedures relating to Utilization Management responsibilities. Provide input into the development of educational material and programs necessary to meet business objectives, members' needs, contractual and regulatory guidelines and staff professional development.

  • Comply with Corporate, Federal, and State confidentiality standards to ensure the appropriate protection of member identifiable health information

  • Develop and maintain department budget. Seek opportunities to contain cost.


  • Bachelor's Degree in Nursing or the equivalent education and experience preferred.

  • Three years case management experience in relevant scope preferred, one year required. Professional certification in a clinical specialty preferred.

  • 3-5 years relevant clinical practice required.

  • Registered Nurse licensed Active/Clear in the state of North Carolina.

  • Experience working with the elderly, blind, and/or disabled population strongly desired.

  • Understanding of and expertise in quality improvement and medical economics.

  • Experience in use of financial information for planning purposes preferred.

  • Excellent analytical and problem solving skills.

  • Proficiency and speed working in all Microsoft office Suite applications.

  • Fluency in a second language desired.

icon no score

See how you match
to the job

Find your dream job anywhere
with the LiveCareer app.
Mobile App Icon
Download the
LiveCareer app and find
your dream job anywhere
App Store Icon Google Play Icon

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
CdbgDr Environmental Review Specialist

ICF International, Inc

Posted 2 days ago

VIEW JOBS 3/18/2019 12:00:00 AM 2019-06-16T00:00 Working at ICF Working at ICF means applying a passion for meaningful work with intellectual rigor to help solve the leading issues of our day. Smart, compassionate, innovative, committed, ICF employees tackle unprecedented challenges to benefit people, businesses, and governments around the globe. We believe in collaboration, mutual respect, open communication, and opportunity for growth. If you're seeking to make a difference in the world, visit to find your next career. ICF—together for tomorrow. Solving the world's most complex challenges. At ICF we make BIG things happen. Let's work together to help Hurricane victims and communities recover and re-build for future resilience. ICF's agile Housing and Community Development Engine is powered by an outstanding team equipped to offer expert advisory services, bring the strength of past performance and a hand's on integrated multidisciplinary approach. Join the ICF team and help make a difference. ICF seeks a CDBG-DR Environmental Review Specialist for a client in North Carolina. In this role you will utilize your experience to work directly with the client. This position is located near the client site in Raleigh, North Carolina. Key Responsibilities: * Document program compliance with federal environmental regulations * Provide expertise to inform developers with building or modifying * Review area-wide (Tier 1) environmental review records prepared by contractors for compliance and accuracy * Review site-specific environmental reviews prepared by contractors for compliance and accuracy * Providing environmental Subject Matter Expertise in all of North Carolina's Action Plan-defined programs including but not limited to housing programs, buyouts and acquisitions, and infrastructure repair * Providing training to state, contract, or local staff To be considered for this role you will need: * 3+ years of direct experience in providing environmental review Subject Matter Expertise for a grantee or subrecipient * Experience authoring or reviewing area-wide (Tier 1) environmental review records and authoring or reviewing site-specific (Tier 2) environmental reviews * Ability to review and provided recommendations for environmental review process within one month of employment * Ability to improve the speed of Tier 2 environmental review approvals within the first two months of employment start date ICF is an equal opportunity employer that values diversity at all levels. (EOE – Minorities/Females/ Protected Veterans Status/Disability Status/Sexual Orientation/Gender Identity) Reasonable Accommodations are available for disabled veterans and applicants with disabilities in all phases of the application and employment process. To request an accommodation please email and we will be happy to assist. All information you provide will be kept confidential and will be used only to the extent required to provide needed reasonable accommodations. Read more about non-discrimination: EEO is the law and Pay Transparency Statement. Michael-NC N Carolina Client Office (NC88) ICF International, Inc Raleigh NC

Manager Utilization Management Review--Managed Care

Amerihealth Caritas Health Plan