Supervisor, Utilization Management Review, Registered Nurse, Remote

Job Brief

BSN. Current and unrestricted NC or compact state 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.

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.

• Monitors staff work assignments and makes appropriate adjustments based on staffing levels, staff experience, and number/request types of authorizations/appeals received.
• 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.
• Stays current with ACFC policies and procedures and Medicaid requirements.
• Assists with the daily operations of licensed and non-licensed professionals on the Utilization Management team.
• Reviews quality audits and shares audit results in a timely manner with associates, providing necessary education and counseling to improve performance.
• Accurately answers questions regarding Plan benefits for members and providers.
• Participates in process reviews and the development of new and/or revised work processes, policies and procedures relating to Utilization Review.
• Responsible for writing and finalizing annual reviews for direct reports with Manager input.
• Works collaboratively with the Manager and identified leadership to develop and implement performance measures, and monitors associates placed on performance improvement plans.
• 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.
• Provides coaching and counseling to improve productivity of staff members within Utilization Management.
• Establishes and maintains positive communication and professional demeanor with internal and external customers, providers and members at all times.

Education/ Experience:

• Working knowledge of Interqual criterion.
• Minimum 3 years of experience in managed care utilization review (prior authorization/concurrent review) in an insurance company/managed care organization.
• While this position is a remote role, the selected candidate will be required to work during business hours in Eastern Standard Time.
• Proficiency with Microsoft Office Suite (Outlook, Word, Excel, and PowerPoint and electronic medical record and documentation programs.
• Current and unrestricted North Carolina (or compact state) Registered Nurse licensure .
• Ability to attend occasional on site meetings in our North Carolina office (based on business need).
• Bachelor’s Degree in Nursing.
• Experience leading a remote team of clinical professionals.
• 3 to 5 years progressive experience in an acute care setting.