RN Manager of Utilization Management - Health Plan

Location: Corpus Christi, TX
Date Posted: 03-30-2018
RN Manager of Utilization Management - Managed Care
Corpus Christi, TX
Your Job Summary:
The role of the RN Manager of Utilization Management is to promote the quality and cost effectiveness of prior authorization and concurrent review functions.  This person is responsible for management and oversight of daily managerial operations pertaining to utilization management; including but not limited to training, development of process and quality review programs that maximize quality while utilizing appropriate resources within the members’ benefit plans and established contracts.   The focus of this position is the care coordination of pediatric members, children with special needs, and those enrolled in the Texas "STAR Kids" program.
Your Benefits: 

This growing organization offers all full-time and part-time benefit eligible employees (regularly scheduled 20+ hrs/week) are eligible for Medical, Dental, Vision, Life, Disability, Paid Time Off, and other voluntary benefits. All employees, regardless of status, are eligible to participate in the 403(b) plan. Medical and Dental benefits are effective on the 1st day of employment. This company encourages its employees to further their development and effectiveness on the job and offers the opportunity to gain further knowledge, skills, growth through a robust Education Reimbursement program. The organization is committed to providing a total compensation program to attract, reward, motivate, and retain qualified and capable employees. This commitment supports the goals and objectives of the organization as well as helps each employee take care of themselves, their families and their future.

Your Background: 
Valid, unrestricted state Registered Nurse (R.N.) license.
Bachelor of Science in Nursing (B.S.N.) or related field required; Master’s degree a plus.
Certification in Case Management (CCM) or Utilization Management (CPUM/CPUR/CPHM) is a plus.
Roughly 3-5 years of acute care clinical nursing experience; higher acuity settings (ICU, CCU, ER, med-surg) preferred.
At least 4-5 years Care Management / Utilization Review / Discharge Planning experience (mix of all preferred).
Around 3-4 years of progressive supervision or management experience within a managed care or hospital environment.
Strong working knowledge of Utilization Review processes in a Managed Care environment is required.
Experience with FACETS, CCMS, InterQual or other healthcare database.
Extensive knowledge of Medicare, Medicaid and similar state health programs, their regulatory guidelines, benefit management and coverage determination, reconsideration, and appeal processes.
Ability to analyze and integrate information and make sound decisions based upon established guidelines.
Resourcefulness as demonstrated by the effective application of professional knowledge to new situations.
Possess planning, organizing, conflict resolution, negotiating and interpersonal skills.
Experience in training, teaching, and coaching staffs to meet operational requirements and goals.
Basic computer proficiency (MS Office Excel, PowerPoint, and Access and Healthcare IT Systems) and typing skills.
Strong oral and written communication skills; ability to interact with all levels of internal and external contacts.
Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.
Bilingual in English and Spanish is a significant plus.

Your Duties:
The Manager is responsible for being the first line resource for inpatient concurrent review and prior authorization staff.  This includes questions regarding procedures, training, and processes to assure compliance with policies and procedures.  The Manager assists the Regional Director of Medical with daily management of concurrent and prior authorization review staff, auditing functions, and assuring that all staff provides a level of customer service that meets or exceeds the organization’s expectations. 
Responsible for the daily management of concurrent review and prior authorization staff.  Understand, promote and audit the principles of Utilization Management to facilitate the right care at the right time in the right setting.  Identify trends or issues in the UM process that requires further evaluation for their quality or utilization implications and bring these items to the attention of the Utilization Management Director.  Communicate effectively and interact with the medical directors, hospitalists, provider offices, staff and health plans daily or as indicated regarding UM and referral authorization issues.  Possess excellent case management skills including but not limited to, development and monitoring of care plans, post discharge calls, Vital Care referrals, hospital contracts, stop loss and DRG.  Organize and facilitate weekly Utilization Management Meetings to disseminate new information.  Verify that benefits are checked via monthly audits of the staff’s production. Verify that the process in place for collecting data for deferred referrals is followed via monthly audits of the staff’s production. Verify that the process in place for processing urgent/stat referrals is followed via monthly audits of the staff’s production. Verify that turnaround times for all statuses are compliant via monthly audits of the staff’s production.  Verify that the denial process in place is followed and compliant via monthly audits of the staff’s production.  Verify that any new process is communicated to the Utilization Management Staff and is followed via monthly audits of the staff’s production. Know and follow the Employee Handbook policies and procedures and be prepared to address those staff members who do not.  Verify that patient confidentiality is maintained by the staff and that HIPAA compliance is observed at all times.
Mike Vega - CHP
Search Consultant

CareNational Healthcare Services

480-264-0620 (CALL – TEXT – FAX)
GET INFORMED with CareNational.tv
Managed Care News and more!
Sign-Up for Job Alerts

this job portal is powered by CATS