Manager, Utilization Management - Must have a MA RN License

Job Summary:

The Manager, Utilization Management is responsible for the oversight of all utilization management activities ensuring consistency of services and achievement of utilization targets.

Essential Functions:

Assist in coordination and management of the pre-determination process of medical and dental services; ensure the consistent application of criteria for authorization decision, and that decisions to deny or reduce services are made by a health care professional who has appropriate clinical expertise

Assist in the development of integrated service delivery to members and oversee utilization management data and processes to maintain industry standards and practices including decisions within allowable timeframes

• Interact with providers and staff to manage benefits aligned with state-based regulations, NCQA and/or URAC regulations, and CareSource policies
• Review and revise workflows to maximize efficiencies
• Monitor productivity and utilization trends
• Oversee CQI activities and ensure audits and staff feedback occur at regular intervals
• Regularly report all utilization management regulatory requirements
• Ensure compliance with and reporting of all regulatory requirements
• Maintain all utilization management reporting and trend data
• Analyze under and over utilization information for impact on member quality of care and outcomes and formulate recommendations based on data
• Develop, maintain and update all departmental policies and procedures; ensure notices of adverse action are provided in accordance with required regulations
• Audit predetermination requests, cases for documentation and interrater reliability per CareSource policy
• Act as liaison with other departments to assist with research and intervention
• Perform any other job related instructions, as requested

Education and Experience:

• Associate’s Degree in Nursing is required and Bachelors of Science in Nursing (BSN) is preferred
• Minimum of five (5) years of clinical experience is required
• Minimum of five (5) years of experience in one of the following is required: case management, utilization management, and/or quality improvement
• Two years of utilization management experience is preferred
• Managed care experience is preferred

Competencies, Knowledge and Skills:

• Beginning Excel, Word and PowerPoint experience
• Experience in data analysis and trending
• Knowledge of utilization management standards and practices
• Communication skills