About the company
In addition to being the largest Medicaid Managed Care Organization in the country, we are proud to be the largest carrier on the Health Insurance Marketplace and a national leader in managed long-term services and support.
Job summary
Perform duties to conduct and manage the day to day operations of the utilization management function. Communicate with staff to facilitate daily department functions.
Job description
Review analyses of activities, costs, operations and forecast data to determine progress toward stated goals and objectives.
Promote compliance with federal and state regulations and contractual agreements.
Develop, implement and maintain compliance, policies and procedures regarding medical utilization management functions.
Develop, implement, and maintain utilization management programs to facilitate the use of appropriate medical resources and decrease the business unit's financial exposure.
Compile and review multiple reports on work function activities for statistical and financial tracking purposes to identify utilization trends and make recommendations to management.
Facilitate on-going communication between utilization management staff and contracted providers.
Develop staff skills and competencies through training and experience. Available to non-clinical staff as a resource for clinical questions.
Qualifications:
Education/Experience:
Bachelor’s degree in related field or equivalent experience.
Bachelor’s degree in nursing preferred.
3+ years utilization management and recent nursing experience in an acute care setting particularly in medical/surgical, pediatrics, or obstetrics and management experience.
Thorough knowledge of utilization management and clinical nursing.
Familiarity with Medicare and Medicaid managed care practices and policies, CHIP and SCHIP.
Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.
License/Certification: RN license. Case Management Certification preferred.
Dental:
Education/Experience:
Bachelor’s degree in related field or equivalent experience.
3+ years utilization management and recent experience in a dental office or dental academic instruction setting and management experience.
Thorough knowledge of utilization management and clinical dentistry.
Familiarity with Medicare and Medicaid managed care practices and policies, CHIP and SCHIP.
Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.
License/Certification: Possess an active, professional and unrestricted license as a Registered Dental Hygienist (RDH) to practice as a health professional in a state or territory of the United States.
The license has a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review.
For Fidelis Care only: NYS unrestricted license as Registered Nurse (RN) License, Licensed Occupational Therapist (OT), Licensed Clinical Social Worker (LCSW) or License Physical Therapist (PT)
Employee Status:
Regular
Job Level:
Manager
Job Type:
Regular