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Utilization Management Manager

Job Title
Utilization Management Manager
Job ID
795269
Begin Date
4/18/14
Duration
Location
Miramar,  FL
Other Location
Description
JOB SUMMARY:  Position is responsible for overseeing the ongoing training, procedural and clinical direction (including policy interpretation) and ongoing management and mentoring of Utilization Management staff. 
           
ESSENTIAL FUNCTIONS
Title:  Utilization Management Manager FLSA:  Exempt- Executive
 
  Key Duties:
  1. Plans, coordinates, resources, develops and evaluates work of assigned staff with responsibility for hiring, firing, disciplining, training  and performing performance appraisals and pay reviews.
  2. Identifies and allocates manpower and resources to assure completion of established objectives within budgetary and schedule guidelines while upholding high clinical standards.  Manages and leads task and projects to a timely completion.
  3. Supervises activities of unit in order to provide adequate clinical support for services, products or process developments, production, service and product problems, and/or to identify possible new areas for clinical explorations.
  4. Responsible for overseeing the ongoing training, procedural and clinical direction (including policy interpretation) and ongoing mentoring and coaching of Utilization Management staff.   Also responsible for efficiencies within the department, including implementing process improvement and policy and procedure reviews and updates as well as for ensuring proper staff training including working in conjunction with management on any training needs.
  5. Responsible for managing the interface between Univita and the customer; responding to requests for program enhancements, inquires, audits, compliance issues or other concerns.
  6. Oversee process of reviewing requests for coverage of benefits and/or medical necessity.  Assures that staff refers cases to the Medical Director per department guidelines.
  7. Overall responsibility for staff interpretation of medical policy and benefit plan descriptions for covered and medically appropriate benefit decisions and overseeing staff that do such
  8. Assures the process of timely communication with providers, agencies and the claims payer regarding authorizations and/or denials or additional documentation needs per customer agreements related to service level expectations
  9. Ensures quality work from the employees while striving for the highest productivity possible without compromise to quality.   Provides input towards system redesign for improved efficiency and quality.
  10. Maintains confidentiality and respect of Patient information in accordance with HIPAA, URAC and company standards, policy and procedures
 
Non essential duties:
  1. This position may require nationwide travel up to 3 – 4 trips per year.
  2. Participate in on-call  after hours/ weekend/ holidays support for the department as scheduled and committee work to promote the Quality Improvement (QI) program and other department or company activities
  3. Interface with the other departments for any UM questions.
  4. Other duties as assigned.
 
 
   
 
 
Levels
QUALIFICATIONS 
Minimum  Qualifications EDUCATION/EXPERIENCE:
  • 3 years supervisory or management experience in an operations setting, preferably health plan administration or other clinical or health related field.
  • Minimum of 2 years experience in utilization management (precertification/prior authorization, claims, appeals) preferred.
  • Minimum of 5 years work experience with older adult population in a community setting, long-term care facility, or other health related field preferred.
  • Clinical education to obtain a RN license.
  • Required to uphold the principles of compliance as outlined in the Code of Conduct and related policies and procedures.  Supports and participates in the mandatory Corporate Compliance Program training initiatives on an annual or more frequent basis, as required.
 
CERTIFICATIONS/LICENSE:
Current, valid and unrestricted RN licensure in State of Florida required.
 
Preferred Qualifications
  • Coding experience
  • Coding certificate
 
 ENVIRONMENT and COGNITIVE /PHYSICAL DEMANDS
  • Office environment
  • Ability to read, hear, speak, keyboard, reason and problem solve.
 Requires prolonged sitting and telephone usage.  Requires the use of office equipment such as computer terminals, telephones or copiers.  Requires normal vision range.  Infrequent lifting up to 15 pounds. 
 
Openings
1

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Univita Health is an Equal Opportunity Employer (EOE/AA) and participates in E-Verify. Univita Health will not discriminate in its employment and employment-related decisions against any applicant or employee based on age, race, gender, creed, religion, national origin, disability, marital status, covered veteran status, sexual orientation, status with respect to public assistance, membership or activity on a local commission, or any other characteristic protected under state, federal, or local law.

 
 
 
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