Responsibilities

The Manager of Delegated Services is accountable for activities and personnel related to Utilization Management (UM) and Claims auditors to manage both delegated commercial and Medicare Benefit products. Manage all aspects of utilization review and claims in accordance with regulatory and accreditation requirements (TDI, CMS, etc.), documentation/policy updates and related education in coordination with the Director of Compliance. Provides direction and leadership for multiple projects, services and associated deliverables of significant complexity and/or impact related to monitoring performance and reporting compliance issues to maintain UM and Claims delegation. Primary contact for UM and Claims delegation audit requests, working directly with external auditors and carrier leadership. Act as a liaison and resource to the carriers regarding contract and regulatory requirements, as well as the communication of new or revised requirements. Also acts as chair for Delegation Oversight Committee and participates in UM Committee.

 

Job Title: Manager, Delegated Services

Location: Pearland Administrative Office

Department: Delegation Oversight

Job Type: Full Time 

Salary Range: $101,147 - $124,947 (Pay is based on several factors including but not limited to education, work experience, certifications, etc.)

 

Qualifications

Education

Required: Bachelor’s degree or graduate level degree.

Preferred: Bachelor of Science in Nursing, Healthcare Administration or a related field.

Experience

Required: 5-8 years supervisory or management experience.

 

5-8 years of health plan, managed care organization, and/ or Utilization Management experience.

 

5 years of auditing/monitoring experience and/or oversight of auditing/monitoring processes.

Preferred: Managed Care, quality, auditing or compliance experience.

 

Experience reviewing/interpreting Medicare and applicable State regulatory requirements, including the 

 

ability to easily access and interpret these guidelines.

 

3 – 5 years of project management experience

 

Nursing experience in support of Utilization Review or Claims processing

License(s)

Required: N/A

Preferred: TX RN or RPh license in good standing

Special Skills

Required: Excellent verbal and communication skills, and organizational skills. 

 

Proficiency in MS office products with intermediate experience in Word, Outlook and Excel required

 

Applied knowledge and understanding of medical policy, benefit design, and interpretation, and problem 

 

Resolution.

Preferred: Epic Experience

 

Knowledge of ICD-10 Coding methodologies, Managed Care payment methodologies, and process 

 

improvement methodology.

 

Knowledge of CMS Guidelines, MCG, InterQual or other medically appropriate clinical guidelines.

 

Knowledge of Utilization Management standards with NCQA and URAC.

Other 

Required: Consistent and prompt attendance at employer worksite is an essential job requirement.

Preferred: Computer literate. 

 

Ability to work from designated office for collaborative / interactive fulfilment of duties; ability to concentrate 

 

in an open-office cubicle environment; interact with other staff members and / or outside associates; perform 

 

telephone and / or computer work for extended periods of time; operate office equipment such as a 

 

computer, telephone, and copy / scan / fax machine; actively participate in department meetings via phone, 

 

computer or in person.

 

Working Environment: Office

 

About Us

Start your career journey and become a part of a community of renowned Healthcare professionals.  Kelsey-Seybold Clinic is Houston’s fastest growing, multispecialty organization with more than 40 premier locations and over 65 specialties.  Our clinics are comprised of more than 600 physicians and as we continue to grow, our focus is providing quality patient care by adding to our team of clinical and non-clinical professionals that work together in a convenient, coordinated, and collaborative manner.  Enjoy the rewards of a successful career while maintaining a work/life balance by joining our team today and changing the way health cares. 

 

Why Kelsey-Seybold Clinic?

Medical, Vision, and Dental Tuition Reimbursement Company Matching 401K Employee Reward and Recognition Program Paid time off for vacation, sick, and holidays Employee Assistance Program Continuing Medical Education allowance