RN Manager of Utilization Management

Location: Oakland, CA
Date Posted: 03-08-2018
RN Manager of Utilization Management - Managed Care
Oakland, CA
Manager of Utilization Management Job Summary:
  • RN Manager of Utilization Management is to promote the quality and cost effectiveness of prior authorization requests as well as concurrent and retrospective 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. 
  • The Manager assists with daily management of staff, auditing functions, and assuring that all staff provides a level of customer service that meets or exceeds the organization’s expectations.
  • Understand, promote and audit the principles of Utilization Management to facilitate the right care at the right time in the right setting. 
  • 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. 
  • Verify that the following processes are communicated to the Utilization Management Staff and are being followed by conducting monthly audits of the staff’s production:
    • Member benefits are being checked, and denial process is clear
    • Process for collecting data for deferred referrals as well as urgent/stat referrals
    • Staff is compliant with turnaround times for all statuses
Manager of Utilization Management 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, Utilization, or Quality Management, such as CCM, CPUM, or CPHQ, is preferred.
  • Roughly 5 years of recent acute care clinical nursing experience.
  • Minimum of 3-5 years’ Utilization Management / Utilization Review / Care Coordination experience, including at least 1 year experience at a health plan or other managed care organization (HMO/TPA/IPA/etc).
  • Around 2-3 years of progressive staff supervision or management experience within a managed care or hospital environment.
  • Strong working knowledge of ICD-10 Coding and Quality Improvement initiatives in a Managed Care environment is required.
  • Extensive knowledge of Medicare, Medicaid and similar state health programs, their regulatory guidelines, benefit management and coverage determination, reconsideration, and appeal processes.
  • Experience in training / teaching staffs to meet operational requirements and goals.
  • Strong oral and written communication skills; ability to interact with all levels of internal and external contacts.
CareNational Healthcare Services
480.478.1635 (CALL – TEXT – FAX)

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