Manager, Utilization Management RN - Peak Health

Utilization Review Manager

This role will be responsible for the oversight of a program that is focused on driving the decrease in care variance, to ensure timely discharges, and to refer members to other plan resources to meet their care conditions. Reporting to the Health Plan Director of Medical Management, the Utilization Review Manager will be an integral member of the health plan's medical management team. The incumbent is a collaborative member of the Medical Management team.

Minimum Qualifications

Education, Certification, and / or Licensure :

1. Bachelor of Science in Healthcare or related field

Experience :

1. Five (5) years of healthcare clinical experience in Utilization Review

Preferred Qualifications

Education, Certification, and / or Licensure :

1. Bachelor of Science in Nursing (BSN)

Experience :

1. Medical Management for Medicare and / or Medicaid populations preferred

2. Utilization Management experience preferred.

Core Duties and Responsibilities

The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Oversees the build and implement care management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews) that are consistent with established industry and corporate standards.

2. Manages the build and implement all care management reviews according to accepted and established criteria, as well as other clinical guidelines and policies.

3. Ensures that interventions are collaborative and focus on maximizing the member's health care outcomes.

4. Supervises the facilitation of the Peer-to-Peer Review process, and work with the Medical Directors to continuously improve member and Provider Network services for this process.

5. Oversees the education that is provided to internal and external stakeholders and partners to continuously improve processes and build network relationships.

6. Facilitates a collaborative environment that focuses on collaboration with other members of the medical management team to identify members whose healthcare outcomes may be enhanced by coaching and / or case management interventions.

7. Educates team members on the data that is collected within the position and facilitate improvement in outcomes within the team.

8. When needed, fills in for staff members to ensure that the operations of the medical management team are never compromised.

9. Commits to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Management.

Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Working Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment

Skills and Abilities

1. Working Knowledge of InterQual and / or Milliman Care Guidelines

2. Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning

3. Excellent written and oral communication

4. Problem solving capabilities to drive improved efficiencies and customer satisfaction

5. Attention to detail

6. Proficiency with Microsoft Office

Additional Job Description

Previous health plan utilization management experience.

RN Licensure Required.

Weekend may be required.

Hybrid Role.

Scheduled Weekly Hours : 40

Shift :

Exempt / Non-Exempt : United States of America (Exempt)

Company : PHH Peak Health Holdings

Cost Center : 2403 PHH Medical Management

Address : 1085 Van Voorhis Rd Morgantown West Virginia

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.