Strategic RN Utilization Management Lead

CareSource Management Services; United States; À distance; USD 83 000 - 133 000; Plein temps

Résumé du poste

CareSource Management Services is seeking a Manager, Utilization Management to oversee all utilization activities, ensuring service consistency and target achievement. You will coordinate pre-determination processes and oversee data, audits, and CQI initiatives.

Required RN licensure with an Associate’s Degree in Nursing; BSN preferred and at least five years in case or utilization management. Strong data analysis, communication, and leadership skills are essential to drive regulatory compliance

Qualifications

• RN licensure required (state of practice)
• Associate’s Degree in Nursing required; BSN preferred
• Minimum 5 years of clinical/utilization management experience

Responsabilités

• Oversee pre-determination processes for medical and dental services with criteria-based authorization
• Coordinate utilization management activities to meet targets and regulatory standards
• Interact with providers to align benefits with state regulations and NCQA/URAC standards
• Monitor workflows, productivity and utilization trends
• Oversee CQI activities and regular audits with staff feedback
• Ensure compliance with regulatory reporting and adverse action notices
• Analyze under/over-utilization data to improve member outcomes
• Maintain department policies and procedures and interdepartmental liaison

Connaissances

Excel basics

Data analysis

Communication

Leadership

Time management

Negotiation

Formation

Associate’s Degree in Nursing

BSN preferred

Description du poste

CareSource Management Services is seeking a Manager, Utilization Management to oversee all utilization activities, ensuring service consistency and target achievement. You will coordinate pre-determination processes and oversee data, audits, and CQI initiatives.

Required RN licensure with an Associate’s Degree in Nursing; BSN preferred and at least five years in case or utilization management. Strong data analysis, communication, and leadership skills are essential to drive regulatory compliance