The Manager for Utilization Management is primarily responsible for the Utilization Management activities, clinical and non-clinical staff. Develops and maintains strong working relationships with payers, brokers and internal departments for all UM services. Coordinates UM activities with other departmental management staff. Supports quality management and accreditation activities; complies with HIPAA and ERISA standards.
- Directs telephone access, utilization management process and coordinates day to day activities.
- Selects, trains, evaluates, develops and supervises clinical and non-clinical staff accordingly. Plans, conducts and monitors staff training
- Acts as the medical management liaison on behalf of the department to specific committees or work groups.
- Collaborates with VP of Medical Management to maintain staffing levels according to enrollment and designated departmental functions.
- Reviews and revises Utilization management policy and procedure manual; coordinates desk top procedures for area and provides support for UM Bridge module including User Acceptance testing and authorizes required rules.
- Participates in Medical Advisory Committee; reporting quality measures; participates in action planning. Works with the VP of Medical Management to ensure compliance of departmental standards.
- Coordinates and monitors reports to payors/clients for UM activities.
- Analyzes department activities using approved metrics and reports on trends and provides recommendations.
- Maintains a continuum of open communication with internal and external customers, especially clients and providers.
- Other duties as assigned.
- Current Washington State RN licenses.
- BA Degree, or higher in health-related field preferred.
- Experience in managed care, utilization management or insurance industry experience.
- Minimum of five (5) years full time equivalent of direct clinical care to patients.
- Minimum three (3) years supervisory experience.
- Strong written, verbal and interpersonal communication skills, including presentation skills.
- Strong organizational and time management skills.
- Proficient in PC applications including Word, Excel, PowerPoint and Outlook.
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How to Apply
Please submit your resume to email@example.com.
Additional information about our company may be found on our website www.fchn.com