RN Director of Utilization Review – Health Plan
Linthicum Heights, MD
Management of staff; new business evaluations; report monitoring;
Responsible for overall resource planning and allocation in coordination with Operations Leadership team
Conducting needs assessment to support changes in overall and new client membership; creation of UM underwriting financial model for new sales and efficiency delivery
Monitoring of workflow and effectively allocating resources to ensure compliance with SLA’s and regulatory standards for all medical management activities including:
UM Call Center
Letter and Verbal Notification
New hire training courses and staffing considerations
Day to day auditing of cases; CAP audits; quality controls; letters audits; ODAG and SARAG daily/weekly/monthly validation, authorization reject files
Responsible for overall Quality Control of Cases including monitoring and reporting for Departmental and individual adherence to expected standards
Identify areas for continuous improvement including training and development opportunities based on Quality trending and analysis
Handling of Internal and External Corrective Actions, identifying root cause, developing related action plans and executing to satisfactory completion
Overall responsibility in maintaining letter inventory controls including routine audits to ensure integrity of template library
Responsible for scheduled ODAG and SARAG UM table validation, integrity of data with respect to regulatory requirements by partnering with IT Development
Responsible to ensure Authorization Rejection files are worked in accordance with established SLAs
All client and internal reporting; ODAG reporting; operational dashboards
Responsible for managing the universe of requiring internal and external reporting for Utilization Management
Partner with Client Management to identify reporting development needed for custom client reporting requirements
Implementing new and updated reporting according to the development life cycle through to client sign off
Developing key controls to ensure reporting integrity, delivery and accuracy with routine testing to validate expected outcomes
Project management and SME for all UM implementation activities. Interaction with internal teams and client. Management from award through warranty period
Drive implementation of new client onboarding for Medical Management product including design of the operational processes, review of the contract, and participation in sales activities and planning for all new sales opportunities
Maintains and oversees a team primarily tasked with performing configuration, diagnosing reported issues, performing validation, and participating in requirements definition
Partner with Customer Care to develop a curriculum for the Medical Management staff. Partner with the Medical Director to develop curriculum for the clinical teams.
Current, valid, and unrestricted Maryland Registered Nurse license.
CCM or CPUR or similar certification is preferred
8+ years of recent experience in Utilization Review or Utilization Management at a health plan or other managed care organization (HMO/TPA/IPA/etc).
5+ years experience as a RN in a lead, supervisory or management role is preferred.
Knowledge of guidelines for Medicaid/Medicare and related state programs is required.
Computer skills to include Microsoft Word, Excel, database use, and basic data entry.