Job Description
Duties/Responsibilities:
Oversees utilization management functions which include timely authorizations related to pre-certification, concurrent review, referrals, and other plan services Develops and monitors goals for staff; provides ongoing feedback and coaching; conducts annual performance reviews; leads by example; and ensures an atmosphere of open communication, teamwork, and ownership and empowerment to make informed decisions Collaborates with medical staff and reviews medical charts to obtain additional information required for appropriate utilization management and to solve complex clinical problems Allocate, monitor, and control resources while delegating and monitoring workloads Develops and analyzes operational and analytical reports to monitor and track operational efficiency Properly documents utilization management activities and rationale for all decisions in electronic medical records systems Functions as a clinical resource for the multi-disciplinary care team on an ongoing basis in order to maximize the quality of patient care while achieving effective medical cost management Additional duties as assigned Minimum Qualifications:
Associates degree RN, LPN, LMSW, LMHC, LCSW, or any other relevant clinical license Work experience demonstrating verbal and written communication skills Experience working independently in a fast-paced environment that requires problem solving skills and handling multiple priorities simultaneously Experience with Microsoft Office Suite applications including Excel, Word, Power Point and Outlook Preferred Qualifications:
RN, LPN, LMSW, LMHC, LCSW, or any other relevant clinical license Masters degree in a related discipline Demonstrated professionalism and leadership skills along with the ability to train, develop, direct, and support staff Experience in managed care, case management, identifying alternative care options, and discharge planning across a variety of treatment settings for high risk, complex populations Certified Case Manager Interqual, Milliman, and/or TruCare knowledge Knowledge of Centers for Medicare & Medicaid Services (CMS), New York State Department of Health (NYSDOH), or MLTCP regulations governing medical management in managed care Work experience in managed care or healthcare industry in utilization management including preauthorization of outpatient or inpatient services Knowledge of utilization management/quality management case philosophies and reporting requirements to NY state and federal agencies. Compliance & Regulatory Responsibilities:
The Manager is responsible for ensuring regulatory compliance with CMS, DOH, internal, and other relevant rules. WE ARE AN EQUAL OPPORTUNITY EMPLOYER.
Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
