JOB POSTING IS EXPIRED
Utilization Management Manager

Job Overview

Description

• Clinical background required (various backgrounds acceptable including nursing, EMT, etc. )
• Strong leadership skills
• Positive, energetic personality with ability to make quick, tough decisions
• Strong communication skills
• Organization skills, multitasking, and follow-through

• Provide oversight and back-up assistance with the day-to-day activities of the UM Nurses. Maintain proficiency in utilization management and act as a resource for health plan staff.  Ensure evidence-based criteria is being utilized to determine member utilization outcomes at the most cost-effective level of care for the Health Plan including investigating alternatives to hospitalization such as Home Health Care and Durable Medical Equipment by utilizing the assessment process and obtaining accurate vital data.                
• Coordinate utilization management responsibilities including telephone duties, physician referrals, admissions and utilization review updates. Complete audits for referral management, air ambulance transfers, surgical procedures, authorization requests, part C validation, Medicare Universe reporting, denials, appeals, grievances, and bed days performed by UM Nurses.  Provide regular updates to the Directory of Quality and Health Care Services and determine appropriate interventions if needed for outlying issues. Provide education and assistance to providers on utilizations management processes and referral requirements.
• Manage hiring selection, training, development, performance evaluations, and performance issues for direct reports.  Ensures appropriate staffing levels necessary for department workload.  Implements changes for continual improvement in services provided and ensure high level of quality is consistent with organization standards.
• Develop and maintain policies and procedures utilizing evidence based, up to date information for services outside of the standard criteria.  Maintain compliance with departmental and operational policies and procedures by providing direct interpretation guidance. Manage vendor contracts as needed.  Ensure appropriate timelines are in place to meet the standards for all lines of business. Prepare and lead Utilization Management Committee meeting packer and meetings. Develop and maintain UM standards to meet National Committee for Quality Assurance (NCQA) accreditation and other regulatory requirements.
• Perform administrative duties which include, but are not limited to preparing annual budgets, attending meetings, compiling and analyzing data such as telephone stats, inpatient analysis, cost savings reports, providing reports to the Director of Quality and Health Care Services on a scheduled basis.  Identifies and reports of problems and problem resolutions, action plans and communication to appropriate co‑workers to the Director of Quality and Health Care Services.
• Provide expertise in the provider/member portal on all clinical aspects for both internal and external customers. Maintain guidelines and all clinical data viewable on the provider/member website and portal. Assist with training and onboarding of new providers on aspects of portal.
• Maintain master tracking document to assist staff in understanding process and networks to improve efficiency. Possess knowledge of utilization patterns and capabilities to ensure appropriate referral practices.  
• Complete all other assigned projects and duties.

1. Strategic Planning and Goal Setting: Proactively manage projects and long-term goals, establish timelines and action owners, ensure commitments are met.
2. Decision Making and Resource Management: Gather information, evaluate impacts and risks, make timely decisions, manage resources responsibly.
3. Leadership and Team Building: Set an example, model respectful and cooperative relationships, ensure team understanding and collaboration, motivate employees, address morale issues.
4. Communication and Relationship Building: Communicate openly and effectively, build commitment and loyalty, manage difficult issues with empathy and clarity, promote a non-threatening environment for expressing opinions. Interact professionally, build rapport, treat everyone with respect.
5. Innovation and Change Management: Implement new ideas and technologies, support change, remove obstacles, ensure resources are available.
6. Performance Management and Development: Set performance and behavioral standards, promote personal accountability, encourage skill development and goal attainment, provide feedback and evaluations, support employee development and succession planning.  Remain current with skills and industry knowledge and seek feedback for continual personal development.
7. Customer Focus and Commitment to Excellence: Anticipate internal and external customer needs, respond proactively and ensure satisfaction. Demonstrate commitment to excellence, deliver quality work.
8. Policy Compliance and Ethical Behavior: Comply with Medical Associates policies and behave in an ethical manner at all times.

Physical Aspects:

Reaching - Extending hand(s) and arm(s) in any direction.
Lifting - Raising objects from a lower to a higher position or moving objects horizontally from position-to-position. This factor is important if it occurs to a considerable degree and requires the substantial use of the upper extremities and back muscles.
Fingering - Picking, pinching, typing or otherwise working, primarily with fingers rather than with the whole hand or arm as in handling.
Grasping - Applying pressure to an object with the fingers and palm.
Talking - Expressing or exchanging ideas by means of the spoken word. Those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly or quickly.
Hearing - Perceiving the nature of sound with or without correction. Ability to receive detailed information through oral communication and to make fine discriminations in sound, such as when making fine adjustments on machined parts.
Vision - 20 / 40 or better in the best eye with or without correction.
Repetitive Motions - Substantial movements (motions) of the wrists, hands and/or fingers.
Sedentary Work - Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
None - The worker is not substantially exposed to adverse environmental conditions (such as in typical office or administrative work).

Medical Associates Clinic & Health Plans is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, pregnancy, age, national origin, marital status, parental status, disability, veteran status, or other distinguishing characteristics of diversity and inclusion, or any other protected status.

Please view Equal Employment Opportunity Posters provided by OFCCP here.