Utilization Management Supervisor Jobs

1 to 3 years Managed Care, Insurance, Call Center Experience

Minimum 1 year general office and/or customer service experience required.

Work experience in healthcare setting required.

Knowledge of medical terminology required

Your career starts now. We’re looking for the next generation of health care leaders.

3 years Billing, health insurance, physician practice, case management, healthcare-related field, or equivalent operations.

Ability to complete data entry, communicate clearly & accurately both in written and verbal communication.

Knowledge of electronic medical records (EMR) and medical terminology.

Communicates and documents all conversations with internal and external key stakeholders according to departmental policy and procedure.

Bilingual in English and Spanish.

Understanding and/or experience with Utilization Management. (R)

Carries out supervisory/management responsibilities in accordance with the organization’s policies, procedures, applicable regulations and laws. Responsibilities include:

Minimum two years of experience in a supervisory capacity in a managed care setting. (R)

Must be knowledgeable of DHCS, CMS, DMHC regulations and NCQA regulatory Population Health standards. (R)

Ability to consistently meet accuracy and timeline requirements to maintain regulatory requirements.

Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)

Identify high cost utilization and refer to Large Case Reinsurance RN and Care Management team as appropriate.

Coordinate necessary resources to achieve member outcome goals and objectives.

Accurately document case notes and letters of explanation which may become part of legal records.

Perform concurrent review of members admitted to inpatient facilities, residential treatment centers, and partial hospitalization programs.

Maintain contact with the inpatient facility utilization review personnel to assure appropriateness of continued stay and level of care.

Review referral and preauthorization requests for appropriateness of care within established evidence-based criteria sets.

Demonstrated experience in utilization management, discharge planning, or transfer coordination.

Previous case management experience preferred.

Must be able to work in a Labor/Management partnership environment.

Bachelors degree in nursing or health related field OR four (4) years of experience in a directly related field.

High School Diploma or General Education Development (GED) required.

Knowledge of Nurse Practice Act, TJC, and other federal/state/local regulations.

Oral & Written Communication Skills

Language Requirement (other than English)

Conduct research beyond medical policy review to make decisions on medication coverage requests.

1 - 3 years in Pharmacy

Problem Solving & Decision Making

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Note: Required professional licensure/certification can be used in lieu of education OR experience, if applicable

2+ years of Health Insurance Utilization Management coordination experience

Customer service expert with excellent organizational and time-management skills

Department: Ascension Care Management Insurance

Responsible for accuracy and completeness of precertification and referral information within the database in accordance with all compliance and regulatory requirements.

Computer savvy and data entry skills

2 years Billing, health insurance, physician practice, case management, healthcare-related field, or equivalent operations.

Ability to complete data entry, communicate clearly & accurately both in written and verbal communication.

Knowledge of electronic medical records (EMR) and medical terminology.

Ability to take direction, offer useful insight into work processes & brainstorm when challenges arise. Strong ability to work collaboratively.

Retrieves medical records and scans documents to assist with the facilitation of the UM department.

Communicates and documents all conversations with internal and external key stakeholders according to departmental policy and procedure.

Medical terminology training, time management skills, organizational skills

Preferred Skills, Capabilities and Experiences:

May act as liaison between Medical Management and internal departments

This position can be filled at Utilization Management Representative II.

Manage incoming calls or post services claims work

Determine contract and benefit eligibility

Demonstrate knowledge of emergency procedures and assist in crisis situations.

Complete all other relevant responsibilities as assigned by the supervisor.

Enter screening and referral information in the electronic health record system.

Completes record audits for adherence to Service Definitions, UM Guidelines, DHSR and Accrediting bodies.

Participate in on call and afterhours coverage, including weekends and holidays as needed.

Driving and travel may be required.

3+ years clinical practice experience, e.g., hospital or behavioral health setting,

Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding

Experience working in the Louisiana Medicaid Behavioral Health system *strongly preferred*.

Utilization review experience strongly preferred.

Licensed addiction counselor (LAC) and/or substance use disorder treatment experience preferred

Ability to multitask, prioritize and effectively adapt to a fast paced changing environment

Conduct discussions with physicians in the Devoted network regarding: medical policies, utilization management, use of resources, and quality.

Five or more years of clinical practice experience.

Perform clinical reviews (i.e., part A, B, appeals, quality of care) and conduct peer to peer discussions.

Participate in inter-rater reliability activities.

Participate in analysis of utilization data and suggest improvement opportunities.

Provide appropriate mentoring and leadership to clinical teams as well as develop relationships to support growth and fiscal responsibility.

3+ years clinical practice experience, e.g., hospital or behavioral health setting,

Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding

Experience working in the Louisiana Medicaid Behavioral Health system *strongly preferred*.

Utilization review experience strongly preferred.

Licensed addiction counselor (LAC) and/or substance use disorder treatment experience preferred

Ability to multitask, prioritize and effectively adapt to a fast paced changing environment

Experience with Utilization Review and/or Prior Authorization, preferably within a managed care organization

1 or more years of Administrative support, Healthcare, or telephonic Customer Service experience

Excellent verbal and written communication skills

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

CGX experience with building cases and generating letters

Proficient and/or experience with medical terminology and/or ICD-10 codes

3+ years clinical practice experience, e.g., hospital or behavioral health setting,

Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding

Experience working in the Louisiana Medicaid Behavioral Health system *strongly preferred*.

Utilization review experience strongly preferred.

Licensed addiction counselor (LAC) and/or substance use disorder treatment experience preferred

Ability to multitask, prioritize and effectively adapt to a fast paced changing environment

Works closely with management team in business office to ensure all internal and external customer service issues are addressed. -

Obtain authorizations for all internal services from patient’s PCP and/or managed care companies. -

Must have excellent interpersonal and communication skills, be very detail-oriented and a self-starter.

Verify Medicaid patient eligibility status for established patients. -

Obtain authorizations for Medipass patients. -

Review daily schedules for potential pitfalls of unusual patient insurance coverage limitations or restrictions.

Monitors staff work assignments and makes appropriate adjustments based on staffing levels, staff experience, and number/request types of authorizations/appeals received.

Assesses candidates and ensures that optimal qualifications are met as a member of the department’s interview team.

Reviews quality audits and shares audit results in a timely manner with associates, providing necessary education and counseling to improve performance.

Responsible for writing and finalizing annual reviews for direct reports with Manager input.

Accurately answers questions regarding CHC benefits for members and providers.

Maintains awareness and complies with Plan CHC authorization timeliness standards based on DHS/NCQA requirements.

Experience with Utilization Review and/or Prior Authorization, preferably within a managed care organization

1 or more years of Administrative support, Healthcare, or telephonic Customer Service experience

Excellent verbal and written communication skills

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

CGX experience with building cases and generating letters

Proficient and/or experience with medical terminology and/or ICD-10 codes

Communicate to management ways to improve processes and productivity of company.

Investigate and manage orthodontic reimbursement inquiries with Client/Provider Engagement, Claims, and Customer Service departments.

Coordinate, manage and distribute incoming faxes to facilitate distribution to appropriate parties within the organization.

Organize, coordinate, and communicate Outpatient Facility Requests to appropriate State and/or Managed Care Organizations.

1 year experience in clerical setting

Knowledge of general computer software.