Manager, Utilization Management - Must have a MA RN License

CareSource; Massachusetts; On-site; USD 83,000 - 133,000; Full time

Benefits offered by this job

Bonus opportunity

Total rewards package

Job summary

CareSource is seeking a Manager, Utilization Management to oversee utilization management activities, ensure consistent criteria for authorization decisions, and monitor regulatory compliance.

The role requires an RN license with at least five years of clinical and UM/quality improvement experience; BSN preferred; strong data analysis, leadership and communication skills; and the ability to work in a collaborative, fast-paced environment.

Qualifications

• Registered Nurse licensure in state of practice is required.
• Minimum of five years of clinical experience.
• Minimum of five years in case management, utilization management or quality improvement.
• Two years UM experience preferred.
• Managed care experience preferred.

Responsibilities

• Oversee pre-determination processes for medical and dental services with credentialed decision makers.
• Coordinate integrated service delivery and monitor UM data and processes.
• Interact with providers and staff to align benefits with regulations and CareSource policies.
• Review and revise workflows to maximize efficiency.
• Monitor productivity and utilization trends.
• Oversee CQI activities and ensure audits and feedback occur regularly.
• Report regulatory requirements for utilization management.
• Maintain UM reporting and trend data.
• Analyze utilization information and recommend data-driven improvements.
• Develop and update departmental policies and procedures; issue notices of adverse action when required.
• Audit predetermination requests and interrater reliability per policy.
• Serve as liaison with other departments for research and intervention.
• Perform other job-related instructions as requested.

Skills

Excel

Word

PowerPoint

Data analysis

Trending

UM standards

Communication

Management

Supervisory skills

Independent work

Attention to detail

Healthcare familiarity

Critical thinking

Training/teaching

Strategic management

Negotiation

Technical writing

Time management

Phone etiquette

Customer service

Decision making

Leadership

Education

Associate’s Degree in Nursing

BSN preferred

Tools

Excel

Word

PowerPoint

Job description

Job Summary

The Manager, Utilization Management is responsible for the oversight of all utilization management activities ensuring consistency of services and achievement of utilization targets.

Essential Functions

• Assist in coordination and management of the pre-determination process of medical and dental services; ensure the consistent application of criteria for authorization decision, and that decisions to deny or reduce services are made by a health care professional who has appropriate clinical expertise
• Assist in the development of integrated service delivery to members and oversee utilization management data and processes to maintain industry standards and practices including decisions within allowable timeframes
• Interact with providers and staff to manage benefits aligned with state-based regulations, NCQA and/or URAC regulations, and CareSource policies
• Review and revise workflows to maximize efficiencies
• Monitor productivity and utilization trends
• Oversee CQI activities and ensure audits and staff feedback occur at regular intervals
• Regularly report all utilization management regulatory requirements
• Ensure compliance with and reporting of all regulatory requirements
• Maintain all utilization management reporting and trend data
• Analyze under and over utilization information for impact on member quality of care and outcomes and formulate recommendations based on data
• Develop, maintain and update all departmental policies and procedures; ensure notices of adverse action are provided in accordance with required regulations
• Audit predetermination requests, cases for documentation and interrater reliability per CareSource policy
• Act as liaison with other departments to assist with research and intervention
• Perform any other job related instructions, as requested

Education And Experience

• Associate’s Degree in Nursing is required and Bachelors of Science in Nursing (BSN) is preferred
• Minimum of five (5) years of clinical experience is required
• Minimum of five (5) years of experience in one of the following is required: case management, utilization management, and/or quality improvement
• Two years of utilization management experience is preferred
• Managed care experience is preferred

Competencies, Knowledge And Skills

• Beginning Excel, Word and PowerPoint experience
• Experience in data analysis and trending
• Knowledge of utilization management standards and practices
• Communication skills
• Management and prior supervisory skills
• Ability to work independently and within a team environment
• Attention to detail
• Familiarity of the health care field
• Critical listening and thinking skills
• Training/teaching skills
• Strategic management skills
• Negotiation skills/experience
• Proper grammar usage
• Change resiliency
• Technical writing skills
• Time management skills
• Proper phone etiquette
• Customer service oriented
• Decision making/problem solving skills
• Leadership experience and skills

Licensure And Certification

• Current, unrestricted licensure in state of practice as a Registered Nurse (RN) is required

Working Conditions

• General office environment; may be required to sit or stand for extended periods of time

$83,000.00 - $132,800.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Organization Level Competencies - Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.