RN Director of Utilization Management - Health Plan

Location: Columbus, OH
Date Posted: 02-01-2018
CareNational
RN Director of Utilization Management - Managed Care
Columbus, OH 
 
Your Job Summary:
 
The role of the Director of Utilization Management is to plan, develop, enhance and direct utilization management in order to improve safeguards against unnecessary or inappropriate use of Medicaid services. Develops and implements effective and efficient standards, protocols and processes, reports and benchmarks that support and further enhances utilization management function and quality of healthcare services.  This person is responsible for management and oversight of daily 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.
 
Your Reward:
 
EXCELLENT BENEFITS AND HIGHLY COMPETITIVE SALARY OFFERED!
This established, nationally-recognized organization is a Fortune 500 company that is committed to the health and happiness of all their staff. They offer a comprehensive benefits package to all full-time, permanent employees including low cost health insurance plan, dental, vision, and life insurance. To assist employees in living a healthier life, they offer either on-site fitness center or discounts to local fitness centers and a comprehensive wellness programs. They also offer free or reimbursed parking, tuition assistance, matching 401(k), employee stock purchase plan, generous PTO plus paid holidays, and much more!
 
Your Background
 
Valid, unrestricted state Registered Nurse (RN) license
Requires Bachelor’s Degree in Nursing (BSN) or related field. Master’s degree preferred.
Certified in Case Management (CCM) or Utilization Management (CPUM/CPUR) preferred.
Roughly 5 years of recent acute care clinical nursing experience.
Minimum of 3-5 years of Utilization Management and Quality Improvement experience.
Around 3 years managerial experience in leadership of a Utilization Management staff within a managed care environment. 
Familiarity with Medicaid managed care practices and policies, CHIP, and SCHIP.
Ability to analyze and integrate information and make sound decisions based upon established guidelines.
Experience in training / teaching staffs to meet operational requirements and goals.
Possess planning, organizing, conflict resolution, negotiating and interpersonal 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.
 
Your Duties:
 
The Director is responsible for being the “final authority” resource for Utilization Management, Review and Authorization staff.  This includes questions regarding procedures, training, and processes to assure compliance with policies and procedures.  Develops and implements effective and efficient standards, protocols and processes, reports and benchmarks that support and further enhances utilization management function and quality of healthcare services.  Ensure provision of appropriate care through prospective, concurrent and retrospective reviews of services.
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 Utilization Management 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 Utilization Management 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 HIPPAA compliance is observed at all times.
 
 
Erik Berg
Search Consultant

CareNational Healthcare Services
erik@carenational.com
https://www.linkedin.com/in/erikberg462/

443.470.8240 (CALL – TEXT – FAX)
CareNational.com
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