Job Summary:
Manages the day to day utilization management function of a team or teams of clinicians ensuring the accurate and timely prior authorization of designated healthcare services, including concurrent and retrospective review of authorization requests, including discharge planning activities when needed (collective referred to as Utilization Review) for the Colorado region. Manages utilization review staff working collaboratively with UM physicians and clinical appeals team, supervises the activities of the unit staff, prepares department for internal and external audits, conducts utilization management audits and ensures compliance with policies and procedures for adherence to governmental and accredited agency standards. Manager provides assistance and feedback to UR staff on a monthly basis.
Essential Responsibilities:
Manages the clinical team and or teams that complete medical necessity reviews for authorization and concurrent requests.
Responsible for the planning and decision-making related to utilization review.
Develops and implements departmental policies and procedures. Develops, implements, and maintains utilization management programs to facilitate the use of appropriate medical resources by health plan members/patients.
Manages monitoring of staff workload, reviews productivity, and conducts quality reviews.
Maintains daily oversight of authorization review work queues, and assignments with staff daily to insure appropriate coverage.
Identifies and monitors services with potential for undesirable variation to ensure accurate and consistent application of benefit and clinical criteria.
Develops and reviews medical necessity criteria and utilization management practices including a formal process of monitoring and evaluating the necessity, appropriateness, efficiency, effectiveness, and safety of medical services to achieve favorable healthcare outcomes.
Work in partnership with the Utilization Management Physicians on affordability and cost initiatives to reduce inappropriate and or over utilization of medical and or behavior health services.
Ensures compliance with national and state regulatory/accreditation requirements related to utilization management by partnering with other departments and facilitating workgroups in maintaining survey readiness to ensure that all annual requirements are met. Engages in monthly/quarterly/annual/triennial internal and external utilization management audits and surveys and delegation oversight audits, as necessary.
Manages and oversees the utilization review management training and education program for Utilization Review staff across the region. Ensures post-course evaluation tools and other materials are developed. Manages training and education schedules. Ensures performance measures are developed and staff is managed to such measures consistently and appropriately. Serves as Subject Matter Expert (SME) for Utilization Review workflow issues, complex cases, denials, and internal/external customers.
Manages including hiring, training, performance evaluations and terminations.
Facilitates on-going communication among Utilization Review staff, internal providers, and external/contracted providers.
Basic Qualifications:
Experience
Minimum three (3) years of clinical and medical utilization/review management experience.
Education
Associate degree in Nursing with current unrestricted license and/or, Masters degree in social work. High School Diploma or General Education Development (GED) required.
License, Certification, Registration
Licensed Social Worker (Colorado) OR Registered Nurse License (Colorado)
Additional Requirements:
Thorough knowledge of utilization management and clinical practice.
Familiarity with Medicare and Medicaid managed care practices and policies, CHIP and SCHIP.
Knowledge of regulatory/accreditation requirements (NCQA, DMHC, DHCS, CMS, Medi-Cal Plan Partners, Special Needs Plan (SNP)).
Preferred Qualifications:
Bachelors degree in nursing preferred.
Recent clinical experience in a hospital, LTACH, AIR or SNF setting preferred.
Case Management Certification preferred.
M-F schedule with one weekend a month on call - Work is currently being performed virtually.