Manager of Utilization Management - Dental Insurance

Location: Tampa, FL
Date Posted: 03-30-2018
RDH Manager of Utilization Management - Managed Dental Care
Tampa, FL
*** Requires Bachelor of Science in Dental Hygiene (BSDH) degree and Registered Dental Hygienist (RDH) license! ***
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 department staff is the Utilization Review and Management of members who are being treated on an Inpatient basis.
Your Benefits: 

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 Registered Dental Hygienist (R.D.H.) license, can be from any state.
Requires Bachelor of Science in Dental Hygiene (B.S.D.H.) or related field.
Certification in Case Management (CCM) or Utilization Management (CPUM/CPUR/CPHM) is a plus.
Roughly 7-10 years of clinical Dental Hygiene experience, preferably in a variety of settings.
At least 3-5 years Utilization Management / Utilization Review experience, directly related to Dental Hygiene.
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, Commercial Dental Insurance experience is acceptable.
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.

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.
Erik Berg
Search Consultant

CareNational Healthcare Services

443.470.8240 (CALL – TEXT – FAX)

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