SIHO Insurance Services
  • - Medical Management
  • Columbus, IN, USA
  • Salary
  • Full Time
  • yes

Utilization Review Clinical Manager

Reports To:    Director of Medical Management

Job Location: Columbus, IN

 

This is a full time, exempt position with responsibility for establishing and updating policies and procedures for all assigned functions.

 

Position Description:

This position acts as a direct liaison between the daily processes of the Utilization Review team and the Director of Medical Management for all aspects of utilization review including health care services, clinical operations, member benefits related to care, coverage questions, transition of care, data reporting and accuracy, and process workflow monitoring.

 

Position Responsibilities:       

  • Assist in monitoring compliance with all local, state, federal, and all accreditation standards and keeping the department updated, which shoud reflect in all policies and procedures
  • Manage multi-level team dedicated to exceeding industry standards through accuracy and timeliness for utilization review
  • ·         Act as a liaison between MM department and Pharmacy Benefit Manager(s) (PBM); monitor and maintain current guidelines for access and utilization by MM department.
  • Act as primary resource for resolution of complex issues that may arise during daily tasks of the Utilization Review team: able to coordinate cross-departmentally on issue resolution
  • Monitor and report on all daily authorization inventory and utilization review procedures to staff and directors
  • Create new, accurate, and verifiable reporting metrics for all aspects of utilization review activities
  • Determine staff performance expectations, metrics, and goals
  • Update and Maintain MM Department new employee training documents in compliance with all local, state, federal, and URAC /all current accreditation standards
  • Work collaboratively with Director of Medical Management and other senior level executives to determine appropriate staffing, efficiency, and accuracy levels of utilization review metrics and processes
  • Proactively identify areas where efficiencies can be created or enhanced in current workflows
  • Lead quality audits, both operationally and clinically based, to ensure accuracy and timeliness of data surrounding authorizations, utilization review procedures, and medical information obtained from providers
  • Oversee communication/communicate with physicians in regards to education on UM policies, practices, and procedures
  • Follow industry trends in utilization review and implement changes to the Utilization Review team on an as-needed basis
  • Other duties deemed necessary by Director of Medical Management or senior level staff

 


 

 

Candidacy Requirements:

  • Outstanding communication skills both written and spoken; excellent presentation skills also preferred
  • Ability to certify in and maintain HIPAA certification at all times
  • RN certification (minimum certification level)
  • Ability to establish key benchmarks and reporting
  • Aligned cross-departmentally with SIHO's organizational Operational Excellence Strategy of timeliness and accuracy
  • Ability to articulate metric management and workflows of Utilization Review Management to stakeholders
  • Ability to motivate staff and co-workers and introduce new processes to staff

 

Preferred Candidacy Skills

  • At least 5 years of work experience in Utilization management
  • Previous, verifiable management skills
  • MHA/MBA
  • Drive to streamline processes and interest in long-standing process improvement

           

 




This position has been closed and is no longer available.
SIHO Insurance Services

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