Utilization Management Manager

GulfQuest is committed to providing quality healthcare for our members, as well as forming strong relationships with our providers and their staff. GulfQuest takes an active role in building and maintaining the relationship between the health plan and the doctor by providing ongoing physician and office staff education with quarterly reporting on various points of interest, as well as monthly communications regarding policies and important memorandums from our Medical Director.

We are seeking a Utilization Management Manager for our Medical Management Department in our Houston office.

PURPOSE: 
The Manager, Utilization Management is responsible for:

·  Day to day supervision of staff responsible for the referral and case management process.

·  Provide oversight and coordinate the utilization process to ensure adherence to Policies and Procedures.

·  Assist with development and revision of Policies and Procedures to ensure compliance with NCQA, CSMA, Health Plan Standards, state and federal regulations.

·  Ensure GulfQuest meets stated policies and procedures as required for delegation.

REQUIREMENT:
Registered Nurse with current license without restrictions to practice in the state of Texas.

EDUCATION: 

·  RN, BSN preferred

·  CCM a plus

EXPERIENCE: 

·  Two years experience in either utilization management, quality assurance, discharge planning, case management, or other cost management programs required.

·  Five years experience in hospital-based nursing and some management experience required.

RESPONSIBILITIES AND FUNCTIONS:

·  Evaluates and insures productivity and performance of all staff assigned to utilization review and Case Management in the Medical Management Department.

·  Supervise and participate in case management processes. Assist in developing new programs in Disease Management, and evaluate cost effectiveness of programs.

·  Assist in education/orientation of the medical management personnel.

·  Resource for completion of denial letters.

·  Works with other departments in a cooperative goal directed manner to achieve company goals (Claims, Provider Relations, Customer Service, and Administration).

·  Assist with the development and revision of policies and procedures as necessary to comply with NCQA, CSMA, Health Plan standards, state and federal regulations.

·  Supervises and participates in the utilization process. Review financial costs associated with referral trends and assist with development of corrective action plans as appropriate.

·  Facilitates TQM activity within the department of utilization management.

·  Provides input on system issues and enhancements. Offer ideas for future enhancements.

·  Implement and provide a process for on-going reporting of activities to the Director of Medical Management, GulfQuest Chief Medical Officer, IPA Medical Directors, Senior Management, and Health Plan Representatives as indicated.

·  Develop a resource list to assist staff in decision-making and problem resolution.

·  Assist Provider Relations staff as needed with office orientation and provider issues.

·  Supports and participates in the IPA UM/QM Committees.

·  Establishes and measures goals and objectives for area.

·  Participates in developing and trending quality monitors. Track and trend data as necessary.

·  Review and analyze utilization patterns to identify area of opportunities for efficient and cost-effective medical care.

·  Participate in the appeals resolution process.

·  Maintain confidentiality of all physicians, patient and personnel issues.

·  Perform other duties as may be assigned.

GulfQuest offers a competitive salary and full range of benefits. Please remember to include Resume and salary requirements. No phone calls accepted. GulfQuest is an EEO/AA employer.