Role Description

Come join Peak Health WVU Medicine to help design and build a health plan from the ground up as the Supervisor, Utilization Management. Reporting to the Manager of Utilization Management, the supervisor will be an integral member of the health plan’s medical management team. The UM supervisor is a collaborative member of the Medical Management team. The incumbent will be an excellent communicator who is ready to take on a new challenge in their career!

Qualifications

• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse License Compact (eNCL).
• Five (5) years of healthcare clinical experience.
• Two (2) years of Health Plan Utilization Management experience.

Requirements

• Bachelor of Science in Nursing (BSN).
• Medical Management for government programs and diverse populations.
• Through understanding of utilization management process and regulatory requirements.
• Medical Management for Medicare and/or Medicaid populations.
• Excellent written and verbal communication skill.

Core Duties and Responsibilities

• Oversee the build and implement care management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews) that are consistent with established industry and corporate standards.
• Manage the build and implement all care management reviews according to accepted and established criteria, as well as other clinical guidelines and policies.
• Ensure that interventions are collaborative and focus on maximizing the member’s health care outcomes.
• Supervise the facilitation of the Peer-to-Peer Review process, and work with the Medical Directors to continuously improve member and Provider Network services for this process.
• Oversee the education that is provided to internal and external stakeholders and partners to continuously improve processes and build network relationships.
• Facilitates a collaborative environment that focuses on collaboration with other members of the medical management team to identify members whose healthcare outcomes may be enhanced by coaching and/or case management interventions.
• Educate team members on the data that is collected within the position and facilitate improvement in outcomes within the team.
• When needed, fill in for staff members to ensure that the operations of the medical management team are never compromised.
• Commit to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Review.

Physical Requirements

• Office work which includes sitting for extended periods of time.
• Maintains confidential home office space.

Working Environment

• Standard office environment.

Skills and Abilities

• Working Knowledge of InterQual and/or Milliman Care Guidelines.
• Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning.
• Excellent written and oral communication.
• Problem solving capabilities to drive improved efficiencies and customer satisfaction.
• Attention to detail.
• Proficiency with Microsoft Office.
• Ability to work under stressful working conditions.
• Ability to handle and maintain confidential information.
• Ability to work cooperatively as a team member and leader in our Utilization Management Department.
• Ability to work within multi-disciplinary groups.
• Ability to work in a fast-paced and rapidly changing environment.
• Extensive working knowledge of Microsoft Office applications (Excel and Word).

Additional Job Description

• Scheduled Weekly Hours: 40
• Shift: Exempt/Non-Exempt: United States of America (Exempt)
• Company: PHH Peak Health Holdings
• Cost Center: 500 PHH Administration