Remote Supervisor Utilization Management Review, PA

AmeriHealth Caritas

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Newtown Square, Pennsylvania, 19073 Category Medical Management and Quality Job Id 29474 Remote

Under the supervision of the Manager for Utilization Management, this position is responsible for providing daily oversight of UM Nurses, UM Technicians and staff members within Utilization Management. Responsibilities include providing clinical, technical and operational support and direction, including organization and monitoring of all medical services. ;Responsible for direct supervisory oversight of professional and front line staff receiving requests for authorizations from external customers which encompasses providers and members, as well as from the internal customers. ;

  • ;Assists with the daily operations of licensed and non-licensed professionals on the Utilization Management team.
  • Monitors staff work assignments and makes appropriate adjustments based on staffing levels, staff experience, and number/request types of authorizations/appeals received.
  • Provides coaching and counseling to improve productivity of staff members within Utilization Management.
  • Assesses candidates and ensures that optimal qualifications are met as a member of the department’s interview team.
  • Plans, develops and supports or conducts orientations, training programs and creates educational material for staff members to improve skills, aid in professional growth and development and to ensure staff’s expertise.
  • Reviews quality audits and shares audit results in a timely manner with associates, providing necessary education and counseling to improve performance.
  • Works collaboratively with the Manager and identified leadership to develop and implement performance measures, and monitors associates placed on performance improvement plans.
  • Responsible for writing and finalizing annual reviews for direct reports with Manager input.
  • Participates in process reviews and the development of new and/or revised work processes, policies and procedures relating to Utilization Review.
  • Accurately answers questions regarding Plan benefits for members and providers.
  • Acts as a liaison with outsides entities, including, but not limited to, physicians, hospitals, health care vendors, social service agencies, member advocates, regulatory agencies.
  • Creates and supports an environment that fosters teamwork, cooperation, respect, and diversity.
  • Establishes and maintains positive communication and professional demeanor with internal and external customers, providers and members at all times.
  • Stays current with ACFC policies and procedures and Medicare requirements.

Education/ Experience:;

  • Associate’s Degree in Nursing. Bachelor’s Degree in Nursing preferred.
  • Current and unrestricted Registered Nurse licensure .
  • While this position is a remote role, the selected candidate will be required to work during business hours in Eastern Standard Time.
  • 3+ years of progressive experience in an acute care setting. ;
  • Minimum 3 years of experience in managed care utilization review (prior authorization/concurrent review) in an insurance company/managed care organization, preferably in Medicare.
  • Working knowledge of Interqual criterion.
  • Experience leading a team in a regulatory and compliance environment.
  • Supervisory experience leading a remote team in health plan operations, specifically Utilization Management. This team consists of clinical professionals of eighteen Clinical Care Reviewers in Prior Authorization and Concurrent Review.
  • Proficiency with Microsoft Office Suite (Outlook, Word, Excel, and PowerPoint) and electronic medical record and documentation programs.