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.
Amerihealth Caritas Health Plan