Manager Utilization Management
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Portland, ME 04104
The Manager is responsible for the day-to-day operations of the Utilization Management functions within the Health Management Department. Responsibilities include compliance with all departmental, organizational, and accrediting policies, processes, and benefit guideline This position monitors appropriate utilization and administration of the case management programs and benefit plans to ensure consistency of decision making, quality of service and cost containment. Additionally, the manager has the responsibility of oversight for utilization departmental operations and decision making in the absence of the Director.
The Manager, works closely with Managers and other members of the Health Management Department as well as other Health Plan Department staff, including Health Services Research and Evaluation, Informatics, Marketing, Product Development& Implementation and Managed Care Applications.
The Manager will ensure that staff comply with applicable regulatory and accrediting body standards (i.e. American Nurses Association (ANA), Case Management Society of America (CMSA) URAC, NCQA).
Ensures that utilization management programs are aligned with current industry evidence-based practice as well as local, national and regulatory compliance standards.
Manages the day-to-day UM operations of the Health Management Department including but not limited to the referral and authorization process, benefit and medical necessity review, clinical auditing, and concurrent review, Regularly monitors program evaluation metrics and measurements to ensure that targeted utilization management interventions remain relevant and appropriate
Frequently monitors staff productivity and performance metrics to ensure a productive and efficient team that strives to have the highest service level possible
Monitors clinical and non-clinical administrative staff performance, conducting annual reviews and ensuring effective staff development. Promotes UM staff engagement in organizational and strategic plans, goals and projects.
Develops and manages strategies and programs designed to evaluate compliance with medical management activities and optimize medical expense.
Participates in technology and system planning and enhancement; recommends and tracks technology modifications that support the utilization management programs.
Manages UM employees consistent with HR policies and procedures to ensure standards and quality management. Ensures UM staff have all required resources necessary to effectively perform assigned duties.
Manages designated budgets effectively. Forecasts FTE and other resource needs to ensure efficient UM operations.
Serves as clinical department representative in Plan committees, focus groups and other strategic interdepartmental initiatives.
Collaborates with other department managers and team members to achieve departmental goals, including the medical directors under Health Plan Medical Affairs.
Identifies opportunities for process improvement and initiates or delegates projects.
Ensures compliance with and integrity of all departmental processes and policies with contractual, regulatory and accreditation requirements
Facilitates approval of new administrative policies; annual review of all departmental policies in conjunction with medical directors as necessary.
Supports the development and tracking of internal Medical Policies that support medical necessity decisions
Works closely with the Director Health Management, medical director staff, and legal counsel on a variety of departmental functions and issues as necessary.
Licensed as an RN in Maine and other appropriate jurisdictions as necessary
BS Degree in Nursing required, Master’s in nursing or related field of study preferred
5-7 years of utilization management experience in a managed care setting
3 + years management experience and leadership roles
CCM required or attained within 24 months from date of hire (effective for new hires)
Excellent interpersonal, verbal and written communication skills
Critical thinking: can identify root causes and implement creative solutions
Ability to prioritize time and tasks efficiently and effectively for self and others
Ability to prioritize and manage multiple competing demands
Ability to function independently
Computer proficiency in Microsoft Office products including Word, Excel, and Outlook
Strong management and leadership skills
Ability to demonstrate and support MPHC Core and Manager Competencies
We are an equal opportunity/affirmative action employer.