Manager of Utilization Management - RN

Bravo Health is a premier provider of managed care services for people with Medicare. The Health Services Department is seeking a Manager of Utilization Management.

 

The Manager for Utilization Management is primarily responsible for the Utilization Management activities, clinical and non-clinical staff. Develops and maintains strong working relationships with all providers and internal departments for all UM services. Coordinates UM activities with other departmental management staff.  Supports quality management and accreditation activities; complies with HIPPA, all regulatory requirements and Medicare guidelines.

 

Essential Functions – Manager, Concurrent Review:

• Acts as medical management liaison on behalf of the department to specific committees

• Directs telephone access, utilization management process and coordinates day to day activities of the department

• Collaborates with Director of Utilization Management and the Vice President of Health Services to maintain staffing levels according to enrollment and designated departmental functions

• Reviews and revises Utilization Management policy and procedures

• Participates in Utilization Management Committee and Quality Improvement Committee; reporting quality measures; participates in action planning

• Reporting Utilization Management statistics and analysis on a monthly basis for over and under utilization as it related to acute and skilled admission and readmissions to the VP of Health Services and Director of Utilization Management.

•Works with the Director of Utilization Management to ensure compliance of departmental standards

• Plan, conduct and monitor staff training

• Coordinate and monitor reports for UM activities

• Analyzes department activities using approved metrics and makes recommendations on matters with significant impact to the department

• Maintains a continuum of open communication with internal and external customers, especially payers

• Performs Inter-rater Reliability for Concurrent Review Staff

• Monitor staff for performance and areas of improvement.

• Develops, establishes, and maintains a work priority system to ensure daily and heavy workloads are fulfilled.

 • Promotes professionalism and exemplary corporate image, by poised and pleasant phone etiquette, manners, appearance, and attitude

Maintains availability and willingness to travel to such locations and with such frequency as the employer determines is necessary or desirable to meet its business needs.

Other duties as assigned by Director of Utilization Management or the Vice President Health Services



 

Qualifications of a Utilization Manager: Registered Nurse with an active PA license Must have at least three (3) years of demonstrated Utilization Management experience in a Managed Care environment. Working knowledge of InterQual CriteriaFive (5) years of experience in a clinical setting.At least 2 years of supervisory/management experience Effective oral and written communication skills are necessaryExcellent interpersonal communication and problem solving skillsStrong organizational and time management skillsProficient computer skills