- Perform duties to conduct and manage the day to day operations of the utilization management function.
- Communicate with staff to facilitate daily department functions.
- Review analyses of activities, costs, operations and forecast data to determine progress toward stated goals and objectives.
- Promote compliance with federal and state regulations and contractual agreements.
- Develop, implement and maintain compliance, policies and procedures regarding medical utilization management functions.
- Develop, implement, and maintain utilization management programs to facilitate the use of appropriate medical resources and decrease the business unit's financial exposure.
- Compile and review multiple reports on work function activities for statistical and financial tracking purposes to identify utilization trends and make recommendations to management.
- Facilitate on-going communication between utilization management staff and contracted providers.
- Develop staff skills and competencies through training and experience. Available to non-clinical staff as a resource for clinical questions.
- Bachelor s degree in related field or equivalent experience.
- Bachelor s degree in nursing preferred.
- 3+ years utilization management and recent nursing experience in an acute care setting particularly in medical/surgical, pediatrics, or obstetrics and management experience.
- 3+ years utilization management and recent experience in a clinical setting.
- Thorough knowledge of utilization management and clinical nursing or dentistry.
- Familiarity with Medicare and Medicaid managed care practices and policies, CHIP and SCHIP.
- 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.
- Possess an active, professional and unrestricted license as a Registered Nurse (RN) or Registered Dental Hygienist (RDH) to practice as a health professional in a state or territory of the United States.
- Case Management Certification preferred.
- Using multiple computer systems; excel & daily use.
- Experience with performance management.
For more information, please contact A-Line Staffing Solutions at 877-782-3334.