Lead, Utilization Review Registered Nurse - Remote in Compact States Only
The Utilization Review Care Manager Lead collaborates with the Director of Utilization Management and Utilization Management Medical Director to oversee the day to day utilization management function of a team or teams of clinicians ensuring the accurate and timely prior authorization of designated healthcare services, including concurrent and retrospective review of authorization requests. Assists utilization review staff working collaboratively with UM physicians, monitors the activities of clinical staff, prepares department for internal and external audits, conducts utilization management audits and ensures compliance with policies and procedures for adherence to governmental and accredited agency standards.
Essential Responsibilities:
- Supports the clinical team that complete medical necessity reviews for authorization and concurrent requests. Responsible for the planning and decision-making related to utilization review.
- Implements departmental policies and procedures.
- Develops, implements, and maintains utilization management programs to facilitate the use of appropriate medical resources by health plan members/patients.
- Monitors staff workload, reviews productivity, conducts quality reviews, and reports findings to the Director of Utilization Management. Maintains daily oversight of authorization review work queues, and assignments with staff daily to ensure appropriate coverage.
- Identifies and monitors services with potential for undesirable variation to ensure accurate and consistent application of benefit and clinical criteria.
- Ensures compliance with national and state regulatory/accreditation requirements related to utilization management by partnering with other departments and facilitating workgroups in maintaining survey readiness to ensure that all annual requirements are met. Engages in monthly/quarterly/annual/triennial internal and external utilization management audits and surveys and delegation oversight audits, as necessary.
- Manages and oversees the utilization review management training and education program for Utilization Review staff across the region.
- Ensures post-course evaluation tools and other materials are developed. Manages training and education schedules. Ensures performance measures are developed and staff is managed to such measures consistently and appropriately. Serves as Subject Matter Expert (SME) for Utilization Review workflow issues, complex cases, denials, and internal/external customers.
- Facilitates on-going communication among Utilization Review staff, internal providers, and external/contracted providers.
- Be available as needed after hours for Utilization Management related inquiries.
Basic Qualifications:
- Minimum three (3) years of clinical and medical utilization/review management experience.
- Minimum two (2) years experience leading and managing teams.
- Bachelor’s degree in nursing with current unrestricted license
- Registered Nurse License (compact licensure)
Additional Requirements:
- Thorough knowledge of utilization management and clinical practice.
- Familiarity with Medicare and Medicaid managed care practices and policies, CHIP and SCHIP.
- Knowledge of regulatory/accreditation requirements (NCQA, DMHC, DHCS, CMS, Special Needs Plan (SNP)).
Preferred Qualifications:
- Recent clinical experience working for health plan, hospital, LTACH, AIR or SNF setting.
- Master’s degree in nursing preferred.
- Case Management Certification.
Pay Range on experience: $92,000-$95,000 MAX
Job Type: Full-time
Pay: $92,000.00 - $95,000.00 per year
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Schedule:
- Day shift
- Monday to Friday
- On call
Experience:
- Utilization review: 3 years (Required)
License/Certification:
Work Location: Remote