Oversees prospective, concurrent, and retroactive Utilization Management (UM) activities for ACL (MLTC) members, including staff leadership, program development, policy and procedure creation and maintenance, and in collaboration with other departments as needed to achieve UM and health plan goals.
-Assist with interviewing, orienting, and supervising UM nurses and/or non-clinical support staff
-Train UM Clinical staff and provide ongoing support and/or identify add’l training opportunities
-Identify improvement activities and contribute UM related items to QI work plan
-Maintain department policies and procedures in alignment with regulatory requirements
-Participate in UM sub-committee; make regular reports to committee on UM activities
-Develop UM reports in collaboration with Analytics and Quality
-Maintain Service Request tracking (IAD’s) and Extension Letter
-Arrange for or deliver training on UM program, concepts, and processes;
-Assist training team with development of training content
-Oversee prospective, concurrent, and retrospective UM activities
-Oversee identification and referral of cases to Case Management
-Oversee identification and referral of cases to Quality for Quality of Care investigation
-Perform audits of UM staff for compliance with regulatory requirements and department procedures
-Serve as UM subject matter expert for ArchCare projects including system development
Bachelor's Degree; NYS RN License Preferred
Five years experience
Requires ability to interpret/extract information and/or perform arithmetic functions.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
-Ability to lead a team required to meet rigid timelines with high accuracy.
-Strong negotiation skills, especially with providers.
-Excellent communication and interpersonal skills.
-Ability to problem solve and adapt to changing business needs.
- Knowledge base of geriatrics and common conditions and syndrome sin the elderly, including frequently used medications and potential side effects, depression, challenging behaviors, Alzheimer's disease, and other related dementia's, behavioral health and issues related to accessing and using DME equipment