The Manager of Utilization Management is responsible for the day to day operational management of Utilization Management (UM) activities and services related to the Dean Health Plan UM Department. These activities include the development of a high performing team, and analyzing the effectiveness of the UM programs. This role also manages, trains and evaluates designated staff. The Manager of UM has direct involvement with Dean Health System resources pertaining to Utilization Management. The position regularly and customarily exercise discretionary powers and independent judgment that directly supports management activities. Performs tasks only under general supervision.
Detailed Job Duties:
Responsible for day to day UM operations, which includes prior authorizations, medical necessity and experimental/investigational UM reviews, application of medical policies and business processes.
Ensure the quality and accuracy of utilization management review decisions and adherence to UM departmental policies; participates in the development of policies and oversees staff activities to ensure compliance with regulatory and accrediting standards. (i.e. NCQA)
Support UM program related initiatives. Obtains and utilizes data for improvement of department processes and key performance metrics. Works with the Director of UM to analyze and propose solutions for utilization trends to help achieve cost reduction over current spend.
Responsible for interviewing, orienting, training, mentoring and work performance evaluations for assigned UM staff. Coordinates orientation and continuing education activities with Sr. Clinical UM Analyst.
Conducts regular staff meetings.
Guides recruitment and supports efforts to increase retention and decrease turnover.
Oversee UM staffing and productivity. Adjusts staffing patterns to provide adequate coverage for utilization management operations during absences and vacancies.
Provides coaching, counseling and employee development and meets individually with staff at least quarterly.
Provides appropriate recognition for exceptional employee performance.
Assists team members in improving utilization management skills and problem solving.
Represents the UM Department by participating on committees, task forces, work groups and multidisciplinary teams, as assigned.
Assists the Director with the oversight and collaboration of programs and vendors to improve outcomes.
Maintains professional relationships with provider community and external customers, and identifies opportunities for improvement.
Collaborates with the Director of UM to manage staff to perform to goals and benchmarks.
Manages and completes assigned work plan objectives and projects on a timely basis.
Assist with the development and maintenance of UM programs. Ensures adherence of UM programs and processes to NCQA and other applicable government regulations and quality initiatives.
Ensure UM team meets performance metrics and work plan requirements. Conducts performance evaluations in a timely manner. Consults with Director of Utilization Management to implement corrective action or disciplinary measures necessary to improve staff performance.
Conduct projects and participates in team activities to identify problems and improve work processes and systems. Reviews and evaluates staff participation, individually and as a team member. Coordinates activities with Sr. Clinical UM Analyst.
Assists and participates in meeting company and department goals such as quality improvement activities.
Promotes timely and effective communication based on individual and/or situational requirements and utilizes appropriate means to ensure adequate information flow.
Acts as a leader and a resource to the UM staff; works collaboratively and supports the efforts of team members.
Performs all other duties as assigned by Medical Directors and/or Director of Utilization Management.
Detailed knowledge of utilization management principles and clinical operations.
Registered nurse with an unrestricted license to practice nursing in the State of Wisconsin, or eligible for licensure in the State of Wisconsin. Maintaining active, unrestricted professional licensure is a condition of continued employment.
Five years clinical background and at least 3-5 years of Utilization Management in a Managed Care setting.
Strong management skills with at least 3 years of previous supervisory experience.
Solid organizational, communication and leadership skills.
Knowledge of applicable state, federal and third party regulations and standards.
Proficient computer skills including Microsoft Office (Word, Excel, Outlook, PowerPoint).
Valid driver's license and personal, reliable vehicle required for work related travel to fulfill responsibilities.
You’ve known us as many names throughout St. Louis, and now, we’re bringing our hospitals, doctors, home care and other services together under one name – SSM Health. With seven hospitals, 350+ physicians, more than 40 physician locations and 12,000 employees, we are part of something bigger and better. We’re connected to a wealth of resources, expertise and advance technology to help you, your fa...mily and our community live long, healthy lives.
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