Utilization Manager
Universal American is a New York Stock Exchange company with annual revenues of more than $2 billion. Through our family of healthcare companies, we provide health benefits to people covered by Medicare and/or Medicaid. We are dedicated to working collaboratively with healthcare professionals in order to improve the health and well-being of those we serve and reduce healthcare costs.
Well-capitalized and highly entrepreneurial, Universal American has been on the cutting edge of healthcare for more than 21 years. We offer Medicare Advantage plans to people with Medicare. We partner with providers in Accountable Care Organizations that serve people with Original Medicare. And we provide array of healthcare services to states, municipalities, health plans and other entities in the world of Medicaid. In everything we do, we focus on improving the coordination of healthcare through collaboration between payers, providers and patients to achieve the best health outcomes possible.
The Inpatient Utilization Management, Manager position will manage a team of clinical staff within a functional area in the Health Services’ Care Coordinator and/or Utilization Management department. This position is responsible for the administration and management of the Health plan’s in-house care coordinator and/or utilization management programs.
Responsibilities:
• Provides leadership to and is accountable for the performance and direction of a team of in-house nurse case managers.
• Responsible for the management and assignment of caseloads, clinical audits, performance evaluations and disciplinary actions as needed.
• Hires and educates staff and business associates as to the clinical model plan and respective responsibilities relative to the plan/department.
• Ensures regular team meetings are conducted for communication and feedback, staff training and development, sharing of program results and collaborative problem solving.
• Is available and accessible to staff, network providers for care coordination and serves as a resource to support utilization management in conducting reviews and implementing appropriate follow up interventions.
• Ensures monthly audits are conducted of case documentation (including tracking logs) to ensure process standards, inter-rater reliability standards are met, and successful outcomes achieved.
• Develops and implements the organization’s Health Services plan in accordance with mission and strategic goals of the organization, federal and state law regulations and accreditation standards.
• Takes a leadership role in department internal and external audits.
• Prepares and presents case management summaries and reports to identifying potential areas of improvement.
• Reports quality of care issues identified during the audit process according to company policy and procedure.
• Develops and supports implementation of overall strategic plan and development in order to achieve health plan financial and organizational goals.
• Develops and establishes necessary operational infrastructure to support the UM/QI program within established benchmarks and model requirements.
• Communicates, collaborates and assures cooperation with network and community physicians, hospital leaders, providers and other vendors regarding care coordination and access to quality, cost effective services.
• Interacts with Contracting and Provider Relations to ensure coordinated approach and support for each department's initiatives and communicates consistent messages in all interactions.
• Adopts and shares best practices with clinical leaders with the HMO/PPO network.
• Supports the implementation of the overall strategic plan and development in order to achieve health plan financial and organizational goals.
• Achieves stated health services targets for quality, utilization and staffing.
• Promotes the plan’s overall organizational and financial goals as well as improvement in overall quality of member’s healthcare as primary focus of any initiative.
• Identifies, trends, and evaluates Health Services assigned staff. Provides daily coaching as needed to improve performance.
• Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable, and defined in the Universal American Corporate and department policies.
• And all other duties assigned by the manager and/or supervisor.
Required Skills:
• Professional verbal and written communication skills, with the ability to clearly articulate thoughts and ideas
• Organizational skills with the ability to handle multiple tasks and/or projects at one time
• Customer service skills with the ability to interact professionally and effectively with providers, third party payers, physicians, and staff from all departments within and outside the Company
• Analytical and interpretation skills including departmental, utilization, financial and operations data
• Decision-making skills with the ability to investigate and weigh alternatives and select the course of action that provides the greatest benefit to the organization
• Creative thinking skills with the ability to ask the needed bigger-picture questions that lead to process and team improvements
• Time management skills with the ability to prioritize and schedule daily activities for the most efficient use of time
• Problem solving skills with the ability to look for root causes and implementable, workable solutions
• Interpersonal skills with the ability to work in a fast-paced environment and participate as an independent contributor with little supervision or as an active team member depending on the situation and needs
• Leadership skills with the ability to empower, engage, motivate, evaluate and manage team members individually and as a group
• Must have a track record of producing work that is highly accurate, demonstrates attention to detail, and reflects well on the organization
Required Experience:
• RN with current Texas licensure with at least five years’ nursing experience in an acute care or managed care setting (unrestricted clinical license)
• Minimum Associate’s degree, required
• Minimum 2 years’ clinical experience in a hospital setting
• Minimum 5 years’ previous supervisory experience that includes Quality Assurance, Care Coordination or Utilization Management experience
• Bilingual and experience with seniors, aged, blind and disabled is a plus
• Maintains a valid driver’s license for any required facility on-site and home visits
• CCM and/or related certification or eligible to take exam within two years of employment
• Experience with statistics, data collection, analysis and data presentation
• Experience with utilization management
• Knowledge of ICD and CPT coding
• Knowledge of Medicare products and regulations, especially for the HMO population
• Personal computer experience should include working with Microsoft Word, Excel, PowerPoint and Outlook at the intermediate level at a minimum