Manager Utilization Management

Description

We are searching for a Manager Utilization Management- To develop all of the processes and procedures for Utilization Management intake, concurrent review and processing of denial and appeals. Assesses the quality of service of Utilization Management and all programs and processes.

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Qualifications:

Bachelor's Degree Nursing Or Master's Degree Speech Language Pathology Or Master's Degree Physical or Occupational Therapy Or Master's Degree Social Work required

One of the following is required:

RN - License-Registered Nurses from Texas Board of Nursing or Nursing Licensure Compact

PT - Physical Therapist Texas Board of Physical or Occupational Therapy Examiners

OT - Occupational Therapist Texas Board of Physical or Occupational Therapy Examiners

TX-SLP - Texas Speech Language Pathology American Speech-Language Hearing Association (ASHA)

LCSW - Lic Clinical Social Worker Texas Behavioral Health Executive Council (TBHEC)

LMSW - Licensed Master Social Worker Texas Behavioral Health Executive Council

3 years Utilization Management Prior Authorization Experience required

2 years Managed care experience with government sponsored programs required

2 years Pediatrics experience preferred

Must live within 50 miles of the Bellaire, TX Healthplan office (6330 West Loop South, Suite 800 Bellaire, Texas 77401)

Responsibilities:

Oversight and development of the processes and procedures for Utilization Management unit of the health plan.

Monitors and audits turn around time, reviews weekly statistics, ensures quarterly audit activity completed as indicated in policy and procedure.

Collaborates with Assistant Director, UM Medical Director or designee in the planning and implementation process to support adherence to regulatory guidelines, NCQA guidelines, TDI regulations, federal and legislative obligations, as well as contractual agreements.

Collaborates with the Chief Medical Officers, Medical Directors and Associate Medical Directors in the appeals process, including investigating the initial review and documentation for decision making as indicated by policy and procedures.

Assessment of trends for future opportunity for improvement in utilization management.

Provides quarterly reporting to HHSC and for the Clinical and Administrative Advisory Committee as assigned.

Identifies areas of inefficiency and facilitates/coordinates resolution inter/intra departmentally by acting as liaison between departments across the health plan.

Participates in interdepartmental teams to represent Utilization Management needs and processes including claims, network development, finance, quality and outcomes management, Provider relations, and Member services.