Manager - Utilization Review - Temporary (6 Month Assignment)
Health Care that Starts with You!
Join a truly mission-driven organization! Independent, nonprofit UCare is recognized as one of the Minnesota's leading health plans. We provide more than 225,000 members across Minnesota and western Wisconsin with the health coverage plans and services they need to maintain and improve their health. The innovative coverage we create makes a difference for Medicare-eligible individuals, individuals and families enrolled in Minnesota Health Care Programs, such as MinnesotaCare and Medical Assistance, and disabled adults with special health care needs. UCare is growing in size, membership, products, geographic coverage, and employees. We're an organization that's going places. Be part of a team that cares about you, be part of UCare.
ABOUT UCAREAt UCare, we deliver high-quality health coverage and services to help members of all ages maintain and improve their health. It's a big job that takes innovative ideas, strategic partnerships, and a commitment to doing the right thing. Above all, it takes a compassionate team that is dedicated to making a real difference in the lives of our members and our communities.WORKING AT UCAREWorking at UCare is more than just a career; it's a mission. A mission that defines us as professionals, unites us as an organization, and shapes how we interact with our members and each other. Our values of integrity, community, quality, flexibility, and respect permeate every aspect of our organization - from who we are and how we act, to what we do and how we do it. We owe our continued success to our employees who proudly embody our mission and values in everything they do. UTILIZATION REVIEW MANAGER - TEMPORARY (6 MONTH ASSIGNMENT)Position DescriptionThis position is responsible to manage staff who perform utilization review functions. Also for interpreting and applying benefit and coverage rules for clinical staff; developing and implementing authorization, notification and referral rules; and coordinating the medical necessity review process. ·Oversee utilization review staff to ensure consistent evaluation and application of the medical necessity criteria, appropriateness of service requests, and efficacy of the services. ·Supervise staff orientation and continuing education on InterQual, other clinical criteria, Plan benefit structures and contracts. Develop tools to monitor and evaluate staff compliance to criteria, benefit structure and contractual indicators.·Monitor staff documentation and activities against regulatory and program requirements and ensure expectations are met.·Manage daily operations of the utilization specialist staff; trains, mentors, coaches; and evaluates individual staff performance. ·Ensure utilization review staff answer phones promptly, respond accurately and within established utilization review timeframes. Assigns and monitors completion of utilization reviews and UR functions delegated to the nursing review staff. ·Share accountability with other Clinical Services leadership for daily monitoring of utilization indicators and performance, identification and escalation of problems, and initiation and evaluation of action plans for achieving utilization targets. Analyzes and reports significant utilization trends, patterns, and impact to appropriate departmental and medical staff committees.·Review select sections in the Provider Manual and member materials related to utilization review requirements are up-to-date and accurate.·Conduct audits and inter-rater reliability testing to ensure staff is interpreting and applying policies and procedures per current regulation. ·Maintain compliance with regulatory/accreditation (NCQA, CMS, DHS, MDH) requirements related to UM by partnering with other departments and facilitating workgroups in maintaining audit readiness. ·Ensure regulatory reporting and requirements are maintained/updated, submitted timely and participates in regulatory/accreditation audits. ·Ensure policies and procedures related to utilization review are up-to-date and accurately reflect current regulation and practice.·Participate and provide UM expertise on UCare workgroup and local workgroups, including UM subcommittee and DHS communications Strategy workgroups.·Provide training to Clinical Services staff as requested by Operations Manager on utilization review activities and other operational matters that impact staff such as, new coverage criteria.·Conduct UM team rounds, develops agenda, maintains minutes and ensures follow through of action plans.·Promote alternative care programs and researches available options including costs and appropriateness of patient placement. Recommends, coordinates and educates providers regarding alternative care options.·Other projects and duties as assigned.EducationBachelor's or Associate Degree or Diploma prepared RN. Current Minnesota State Board of Nursing license required.Required ExperienceTwo years' experience in Medicaid or Medicare Advantage programs with at least one years' experience in utilization management. One year direct supervisory/management experience required. Preferred ExperienceExperience in using software programs in support of utilization review/case management functions.THE UCARE DIFFERENCEUCare is proud to be a recognized Star Tribune Top Workplace for the 8th consecutive year. As a part of our collaborative team, you'll experience the rewards that come with helping others and seeing the positive results of your hard work. We value and respect each individual's ideas and contributions, and give you the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, a myriad of volunteer activities, and a number of other rewards. If you're looking for a welcoming environment that celebrates what you have to offer, helps you build on your strengths, and gives you the opportunity to truly make a difference, we invite you to apply. As an Equal Opportunity/Affirmative Action Employer, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.
Enter a highly collaborative environment where people are truly engaged, and feedback is valued. You'll enjoy a competitive salary and benefits, as well as a host of other perks, including a nationally recognized wellness program, and a bright, open, award-winning office space in Northeast Minneapolis just minutes from major freeways and retail centers.
At UCare, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.