Manager, Utilization Management - Must have a MA RN License

Job Summary:

The Manager, Utilization Management is responsible for the oversight of all utilization management activities ensuring consistency of services and achievement of utilization targets.
Essential Functions:

- Assist in coordination and management of the pre-determination process of medical and dental services; ensure the consistent application of criteria for authorization decision, and that decisions to deny or reduce services are made by a health care professional who has appropriate clinical expertise

- Assist in the development of integrated service delivery to members and oversee utilization management data and processes to maintain industry standards and practices including decisions within allowable timeframes

- Interact with providers and staff to manage benefits aligned with state-based regulations, NCQA and/or URAC regulations, and CareSource policies

- Review and revise workflows to maximize efficiencies

- Monitor productivity and utilization trends

- Oversee CQI activities and ensure audits and staff feedback occur at regular intervals

- Regularly report all utilization management regulatory requirements

- Ensure compliance with and reporting of all regulatory requirements

- Maintain all utilization management reporting and trend data

- Analyze under and over utilization information for impact on member quality of care and outcomes and formulate recommendations based on data

- Develop, maintain and update all departmental policies and procedures; ensure notices of adverse action are provided in accordance with required regulations

- Audit predetermination requests, cases for documentation and interrater reliability per CareSource policy

- Act as liaison with other departments to assist with research and intervention

- Perform any other job related instructions, as requested

Education and Experience:

- Associate’s Degree in Nursing is required and Bachelors of Science in Nursing (BSN) is preferred

- Minimum of five (5) years of clinical experience is required

- Minimum of five (5) years of experience in one of the following is required: case management, utilization management, and/or quality improvement

- Two years of utilization management experience is preferred

- Managed care experience is preferred

Competencies, Knowledge and Skills:

- Beginning Excel, Word and PowerPoint experience

- Experience in data analysis and trending

- Knowledge of utilization management standards and practices

- Communication skills

- Management and prior supervisory skills

- Ability to work independently and within a team environment

- Attention to detail

- Familiarity of the health care field

- Critical listening and thinking skills

- Training/teaching skills

- Strategic management skills

- Negotiation skills/experience

- Proper grammar usage

- Change resiliency

- Technical writing skills

- Time management skills

- Proper phone etiquette

- Customer service oriented

- Decision making/problem solving skills

- Leadership experience and skills

Licensure and Certification:
- Current, unrestricted licensure in state of practice as a Registered Nurse (RN) is required

Working Conditions:
- General office environment; may be required to sit or stand for extended periods of time

Compensation Range:
$83,000.00 - $132,800.00
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary Organization Level Competencies

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Fostering a Collaborative Workplace Culture

- Cultivate Partnerships

- Develop Self an