TOGETHER WITH OUR PARTNERS, COMAGINE HEALTH WORKS TO IMPROVE HEALTH AND CREATE A BETTER HEALTH CARE SYSTEM SO THAT PEOPLE AND COMMUNITIES WILL FLOURISH.
WE OFFER A COMPETITIVE PAY AND BENEFITS PACKAGE PLUS EMPLOYMENT WITH COMAGINE HEALTH QUALIFIES IF YOU APPLY FOR THE PUBLIC SERVICE LOAN FORGIVENESS (PSLF) PROGRAM!
WHAT YOU’LL BE DOING FOR US:
- Provide operational management of clinical staff who provide utilization review, and/or specialty reviews.
- Provide operational management of non-clinical staff who provide customer service assistance to internal and external customers, enter document request for utilization review and other medical management services, quality audit validation to identify suspected, fraud, waste, abuse, PHI violation, member and provider eligibility.
- Develop, implement, and maintain departmental policies and procedures, staffing protocols, training programs, quality management programs to include quality assurance reviews & reporting and department budgets.
- Ensure that department fully meets all required legal, contractual and accreditation standards as well as compliance with corporate policies.
- Participate in business/product development, proposals, and customer relations activities. Conduct prospective, concurrent, and/or retrospective utilization management reviews, as applicable.
Ensures the integrity and high quality of utilization management services
- Accepts utilization management assignments when work volumes or case complexities require managerial back up
- Collaborates with the development and implementation of a quality management program, including an on-going internal quality control (IQC) system that provides on-going performance monitoring for compliance with contractual requirements, performance measures accreditation standards
- Collaborates with medical affairs and staff in developing guidelines and protocols for clinical review staff in referring, consulting, and staffing cases/reviews with Medical Directors and physician/practitioner consultants and dentists.
- Develops and implements, through collaboration with staff and other managers, the necessary operational policies, and procedures to meet contractual requirements, customer expectations, accreditation standards, and organizational needs
- Monitors and maintains adequate access by providers, customers, patients/clients, and others with staff to provide the timely provision of Utilization Review services
- Reviews Utilization Review reports, appeal letters, and other sensitive documents to ensure they meet contractual requirements, accreditation standards, performance measures, timeframe requirements, and service standards
Efficiently and effectively manages financial responsibilities
- Develops and monitors the productivity standards for the staff to ensure there is efficient and effective delivery of services by the appropriate number and skill level of staff
- Develops timely and appropriate budgets that include sufficient staffing and other resources to meet the contractual requirements, case/review volumes, service standards, and organizational goals
- Ensures compliance with finance and accounting policies and procedures, which includes but is not limited to the delegations of authority
- Initiates timely and appropriate managerial interventions to improve compliance with the budget when expenditures are not in line with budget
- Monitors unbilled hours and open cases/reviews to ensure that there is timely, accurate, and appropriate billing by staff
Efficiently and effectively manages financial responsibilities
- Develops and monitors the productivity standards for the staff to ensure there is efficient and effective delivery of services by the appropriate number and skill level of staff
- Develops timely and appropriate budgets that include sufficient staffing and other resources to meet the contractual requirements, case/review volumes, service standards, and organizational goals
- Ensures compliance with finance and accounting policies and procedures, which includes but is not limited to the delegations of authority
- Initiates timely and appropriate managerial interventions to improve compliance with the budget when expenditures are not in line with budget
- Monitors unbilled hours and open cases/reviews to ensure that there is timely, accurate, and appropriate billing by staff.
- Effectively works with customers, including business development activities
- Participates in responses to requests for proposals (RFPs), product development, and other business development activities
- Promotes, monitors, and improves positive customer service behaviors, communications, and attitudes by all staff in the provision of services to all stakeholders
- Provides timely, appropriate, and responsive communications and interventions when necessary with providers, patients/clients, customers, and other stakeholders to resolve their concerns, questions, and issues
- Represents the products/services of the department through the active participation in customer conference calls, customer meetings, and educational seminars
Complies with policies and procedures, administrative assignments, and other projects
- Develops, monitors, and reports on departmental goals, standards, and objectives through collaboration with the Vice President, Medical Director, Operations Director, staff, and other managers
- Ensures that the Vice President, Operations Director, or designee is informed in a timely manner regarding significant operational issues, performance measures, complaints/grievances, compliments, quality management initiatives, staffing concerns, and other relevant topics
- Maintains compliance with organizational policies and procedures, including but is not limited to the strategic plan, organizational structure, confidentiality, safety, and complaint/grievance resolution
- Monitors completion of timecards to ensure staff's accuracy, timeliness, and compliance with related policies and procedures
Required Skills
WHAT WOULD MAKE YOU A STRONG FIT FOR OUR ROLE:
- Intermediate MS Office Suite proficiency
- Working knowledge of Medicaid, or commercial insurance preferred
- Demonstrates ability of sound clinical judgment and administrative leadership skills
- Ability to understand, organize and delegate complex work tasks to staff
Required Experience
REQUIRED EXPERIENCE:
- BA/BS in a related field; equivalent combination of education and/or work experience in related field may be substituted
- Current, active, unrestricted RN licensure in the (District of Columbia and Maryland) required
- 5 years of utilization/case management experience
- 2 years of management experience, including financial management