Director, Utilization Management

Linthicum Heights, MD

Posted: 01/03/2019 Category: Registered Nurse Job Number: 23849
Position Purpose:
  • 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.
Qualifications:  
  1. Bachelor' s degree in Nursing or equivalent experience. 1+ years of utilization management and/or case management experience.
  2. ​​​Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
  3. ​​​​​​​5+ years of nursing experience in an acute care setting or medical/surgical, pediatrics, or obstetric in a managed care environment.
  4. Current state’ s nursing license.
For more information, please contact our office at 877-782-3334.
 

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