Manager, Utilization Management (Physical Health)

What you'll be doing: Perform duties to conduct and manage the day to day operations of the utilization management functions to include denials. Communicate with departmental and plan administrative staff to facilitate daily operations of the utilization management functions. Ensure compliance with established referral, pre-certification and authorization policies, procedures and processes. Facilitate ongoing communication between care management staff, utilization management staff and contracted providers. Maintain compliance with URAC, federal and state regulations and contractual agreements, including HIPAA. Develop, implement and maintain compliance regarding medical utilization management and appeals functions. Monitor the effectiveness of existing outreach and intervention efforts. Ensure appropriate medical necessity review for all levels of care and assure appropriate knowledge, education and interventions are conducted for members defined to be at risk. Monitor data, trends and potential quality improvement opportunities including provider issues, service gaps, member needs. Develop staff skills and competencies through training and experience.

What your background should be: 3+ years of utilization management experience. Knowledge of utilization review procedures, experience in psychiatric health care settings and familiarity with all levels of mental health treatment. Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff. Unrestricted licensed RN in applicable state.

Who is the client company: The client company is a diversified, multi-national healthcare enterprise that provides a portfolio of services to government sponsored healthcare programs, focusing on under-insured and uninsured individuals.; If you are interested in this position, send your resume to apply@kochdavis.com