ConnectiCare is a leading health plan in the state of Connecticut. A local company for more than 35 years, ConnectiCare has a full range of products and services for businesses, municipalities, individuals and those who are Medicare-eligible. By striving to make it easy for members to get the care they need, ConnectiCare leads the individual market in the state, and is ranked among the top commercial health plans in the nation, according to the National Committee for Quality Assurance. ConnectiCare is a subsidiary of EmblemHealth.
W_e’re looking for individuals who want to make a difference in the communities we serve. If you want to join a local team and help change the way health care is delivered, ConnectiCare is the place for you._
SUMMARY OF JOB: Direct supervision of the Medical Management Operations Concurrent Review utilization management clinical and non-clinical staff, ensuring accurate administration of benefits, execution of clinical policy and timely access to appropriate levels of care.
RESPONSIBILITIES:
- Under the direction of the Manager, is responsible for the execution of efficient departmental processes designed to manage inpatient utilization within the benefit plan.
- Contributes to the overall success by promoting /advancing the department mission of effectively facilitating care and improving inpatient concurrent review outcomes.
- Responsible for the supervision of the clinical and non-clinical staff, ensuring the timely and appropriate execution of day-to-day inventory and quality management of inpatient concurrent reviews.
- Evaluates trends of inpatient volume across facilities, aligning staff accordingly to handle case load. Performs ongoing analysis to make recommendations to the department manager regarding volume, case type, longevity and acuities of inpatient stays.
- Fosters development and maintenance of facility case management/UM department relationships with the internal concurrent review team by establishing and maintaining clinical staff alignment to assigned facilities.
- Ensures that staff adhere to the proper entry and maintenance of documentation in the Medical Management platform meeting defined timeframes and performance standards, including the communication of concurrent decisions and important benefit information to providers and members in accordance with applicable federal and state regulations, and NCQA and business standards.
- Tracks and reports statistics on care management and/or utilization management activities, process measures (e.g. timeliness), quality results, and other measures that affect departmental objectives.
- Organizes after-hour and weekend coverage, as required.
- Coach and mentor to staff to ensure understanding of utilization management concepts and effectively apply the concepts to managing members’ health care needs.
- Ensures compliance with State, Federal and NCQA requirements related to utilization management activities.
- Under the direction of the Manager; trains, evaluates and develops assigned staff.
- Develops, monitors, and communicates performance expectations and plans for all direct reports and conducts performance reviews within specified timeframe. Provides feedback on a regular basis. Assists with resolution of employee performance issues.
- Maintains an environment of quality improvement through continuous evaluation of processes and policies. Identifies and recommends new technologies and process efficiencies.
- Interacts with various departments throughout the organization and contributes to the resolution of interdepartmental issues. Leads and develops team to quickly assess and diagnose root causes to problem areas.
- Actively participates on assigned committees and projects.
- Performs duties of a care manager or utilization manager as needed.
- Performs other duties as assigned.
Required Skills
QUALIFICATIONS:
- RN, licensed in Connecticut. Bachelor’s Degree in Nursing, health care, or business, or an equivalent combination of education and experience
- At least 2 years of managed care experience preferred
- At least 5 years of clinical experience required; supervisory experience preferred
- State of the art knowledge of care management tactics
- Strong oral and written communication and interpersonal skills
- Strong organizational skills
- Strong knowledge of Microsoft Office products including Word, Excel, and Access
ESSENTIAL JOB FUNCTIONS:
- Primarily sedentary
- Must be able to use standard office equipment
ConnectiCare is an equal opportunity employer. M/F/D/V
ConnectiCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Required Experience