Manager, Utilization Management
hace 1 mes
Why This Role is Important to Us:
Commonwealth Care Alliance's (CCA) Clinical Effectiveness (Authorization) Unit is primarily responsible for the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services,procedures, and facilities under the provisions of CCA's benefits plan.The Manager, Utilization Management is responsible for overseeing and managing the daily operation of the Utilization Management Review Nurse and Specialist staff responsible for conducting centralized clinical review and authorization creation for centrally-authorized services. This position has a key role in ensuring CCA meets CMS compliance standards in the area of service decisions and organizational determinations.The Manager, Utilization Management reports to the Director of Clinical Effectiveness.
What You'll Be Doing:
Oversees clinical decision review for services requiring prior authorization in a variety of clinical areas,
including but not limited to surgical procedures, Medicare Part B medications, long term services and supports (LTSS), and home health (HH).
Maintains and optimizes Standard Operating Procedures related to authorization review
Ensures timely and accurate communications of medical necessity review results to the original requester (e.g., primary care team, specialty providers, vendors) in compliance with regulatory and contractual requirements
Manages the process for escalated reviews in accordance with Standard Operating Procedures.
Provides guidance to UM Nurses and clinical teams as needed
Liaises with clinical teams and re-insurer on high cost cases Ensures that department and organizational policies and procedures as well as regulatory and contractual
requirements and other regulatory reporting needs are met.
Tracks and monitors team's performance against targets; identifies,
recommends, and implements opportunities for improvement as needed
Investigates and resolves member complaints and grievances related to relevant services and supports;
conducts audits and performs quality assurance
What We're Looking For:
Associate's Degree in Nursing, Bachelor's Degree preferred
Registered Nurse licensed in the Commonwealth of Massachusetts in good standing.
3-5 years utilization management experience required
3+ years experience working in a health plan, specifically with utilization management required
3+ years of management experience preferred
Will be required to pass CCA's credentialing process.
Demonstrated ability to establish and manage performance and outcome metrics.
Excellent collaboration and communication skills with the ability to partner effectively across the organization and with external partners.
Familiarity with Interqual criteria applied to procedures
Flexibility and understanding of individualized care plans
Strong strategic thinker and tactical performer
Strong project management skills with the demonstrated ability to handle multiple projects.
Ability to establish and maintain positive and effective work relationships with internal staff, external vendors,and state and federal agencies
Proven skills and judgment necessary for independent decision-making.
Excellent organizational, time-management and problem-solving skills
Strong management skills
Ability to influence decision making
English required, bilingual preferred.
EEO is The Law
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled
Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.
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