RN Utilization Management Leader

CareSource; Massachusetts; Presencial; USD 83.000 - 133.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Bonus opportunity

Total rewards package

Descripción de la vacante

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.

Formación

• 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.

Responsabilidades

• 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.

Conocimientos

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

Educación

Associate’s Degree in Nursing

BSN preferred

Herramientas

Excel

Word

PowerPoint

Descripción del empleo

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.