Director, Utilization Management
Linthicum Heights, MD
- Oversee operations of the referral management, telephonic utilization review, prior authorization functions, and case management programs.
- Ensure compliance government and contractual guidelines and the mission, philosophy and objectives of Corporate and the health plan.
- Oversee the operations of the referral management, telephonic utilization review, prior authorization, and case management functions.
- Support and perform case management, disease management and on site concurrent review functions as necessary.
- Provide support to Provider Relations issues related to Utilization issues for hospitals and physician providers.
- Coordinate efforts with the Member Services and Connections Departments to address members and providers issues and concerns in compliance with medical management requirements.
- Maintain compliance with National Committee for Quality Assurance (NCQA) standards for utilization management functions for the prior authorization unit.
- Develop, implement and maintain policies and procedures regarding the prior authorization function.
- Identify quality and risk management issues and facilitate the collection of information for quality improvement and reporting purposes.
- Compile and review multiple reports for statistical and financial tracking purposes to identify utilization trends and assist in financial forecasting.
- Bachelor' s degree in Nursing or equivalent experience. 1+ years of utilization management and/or case management experience.
- Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
- 5+ years of nursing experience in an acute care setting or medical/surgical, pediatrics, or obstetric in a managed care environment.
- Current state’ s nursing license.