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Clinical Effectiveness Manager
hace 4 semanas
We are seeking a highly skilled Clinical Effectiveness Manager to oversee the daily operation of our Utilization Management Review Nurse and Specialist staff. This role is responsible for ensuring timely and accurate communications of medical necessity review results to the original requester, in compliance with regulatory and contractual requirements.
Key Responsibilities- Oversee clinical decision review for services requiring prior authorization in various clinical areas, including surgical procedures, Medicare Part B medications, long-term services and supports, and home health.
- Maintain and optimize Standard Operating Procedures related to authorization review.
- Ensure timely and accurate communications of medical necessity review results to the original requester.
- Manage the process for escalated reviews in accordance with Standard Operating Procedures.
- Provide guidance to UM Nurses and clinical teams as needed.
- Liaise with clinical teams and re-insurer on high-cost cases.
- Ensure that department and organizational policies and procedures, as well as regulatory and contractual requirements, are met.
- Track and monitor team's performance against targets; identify, recommend, and implement opportunities for improvement as needed.
- Investigate and resolve member complaints and grievances related to relevant services and supports.
- 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.
Commonwealth Care Alliance is an equal opportunity employer. We are committed to diversity and inclusion in the workplace. We welcome applications from qualified candidates who share our values and are passionate about delivering high-quality healthcare services.
