Director, Clinical Utilization Management (RN)
Vacancy expired!
Job Description
· Enables supervisors and team members to ensure consistent quality service to provider and members
· Communicates with supervisors, employees and customers to ensure prompt and courteous attention to all questions regarding products and services
· Responsible for knowing the intricacies and compliance standards of all key programs and contracts
· Refers all complaints to director of compliance, works collaboratively with the compliance department to investigate complaints and correct errors
· Handles and reviews disciplinary actions directly with employees, i.e., verbal warnings, records of discussion, and formal disciplinary documentation. Collaborates with Human Resources to ensure adherence to company policies
· Continuously coach the team to ensure the individual and team performance goals are achieved
· Partners with Workforce Planning to ensure appropriate resources are allocated to meet workload demand
· Monitors staff work assignments and coordinates with clinical management team to make appropriate adjustments based on staffing levels, proficiency, types of request, and amount of cases received
· Serves as first point of escalation for procedural and technical issues and coach staff regarding how to effectively resolve the issue(s)
· Tracks and monitors team performance; provides feedback
· Conducts formal performance appraisals of direct reports and prepares and communicates performance reviews and development recommendations
· Assists with service restoration efforts during emergencies
· Supervises a team of clinical staff with varying professional license and education levels
· Serves as an additional training resource to the clinical review team
· Accurately answers questions regarding Plan benefits for members and providers
· Develops and implements process improvements to increase operational efficiencies
· Promotes business focus which demonstrates an understanding to the company’s vision, mission, and strategy
· Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others
· Utilizes knowledge of telephony, ACD, workforce, and related systems to manage daily phone metrics
· Performs other related duties and projects as assigned
· Participates in the HealthHelp Quality Management Program as required
· Adheres to all HIPAA, state and federal regulations pertaining to the clinical programs
· Adheres to both URAC & NCQA standards pertinent to their job description
Qualifications
· Graduate of an accredited school of nursing
· Current active unrestricted RN license required
· Bachelor’s degree in a health related field required; Masters preferred
· 5-10 years acute care experience
· Minimum 5 years experience in UM managed care setting required
· Minimum 5 years experience in utilization management preferred
· Minimum 5 years of progressively responsible supervisory experience in a managed care environment preferred
· Strong interpersonal skills at both individual and team level
· Excellent oral and written skills
· Proficient leadership and facilitation skills
· Ability to utilize critical thinking skills
· Excellent organizational skills
· Ability to work in a fast-paced evolving environment, on-call after hours work may be required
· Highly motivated, self-starter who works independently using all available resources, policies, and procedures to work effectively and meet deadlines in an atmosphere of multiple projects and shifting priorities
· Demonstrated leadership and facilitation skills
· Demonstrated knowledge and experience in using critical thinking skills
· Experience in team interactions and improvement methods/projects (e.g., coaching quality and productivity)
· Knowledge of Microsoft Office and programs including Outlook, PowerPoint, Excel, Word and Visio
Additional Information
All your information will be kept confidential according to EEO guidelines.
Vacancy expired!