Duration: Full Time
Job ID: 213378 (21971588)
Category: Risk Management RN Job
Contact: April Estes
Call: (720) 439-2609
Practice Type: Hospital
RN Manager, Utilization Management - 213378 (21971588)
- Manage the operations and support team within Health Care Services including the Call Center, Utilization Management or Care Management intake & review functions which includes but is not limited to prior authorization, concurrent review (CCR), Claims, skilled nursing facility (SNF) Review and care management services.
- Provide oversight and direction for systems and tools used internally by staff and externally by provider partners to assist in Medical or Care Management operations.
- Achieves organizational performance standards for Call Center activities, prior authorization, CCR review, SNF review, Claims Audit, Care Management and other areas as deemed appropriate.
- Prepares and manages budget for applicable area(s).
- Manages coordination of all work, quality improvement activities, projects, objectives and staffing of the department by working with other Managers and Supervisors within Health Care Services.
- Evaluates performance and initiates personnel actions such as hiring, merit increases, probationary and periodic reviews, promotions, work plans and disciplinary actions.
- Medical, dental and vision insurance coverage that start on your first day
- Retirement program that helps you prepare for your future
- Life and AD&D insurance
- Health Reimbursement and Savings Accounts (HRA, HSA, FSA)
- Health assessment and personal coaching to help you meet your goals
- Incentives for participation in healthy activities
- Caregiver Assistance Program (for employees) offering work/life services, resources and expertise when you need it
- Weight management, tobacco cessation and diabetes programs
- Volunteers in Partnership program to match you with volunteer opportunities that support our communities
- Support for life events such as birth, adoption, marriage or other changes to your family
- Ergonomics and injury prevention to promote safe work environments
- Paid time off
- Disability benefits
- Tuition reimbursement to support your education as you tackle your career goals
- Bachelor’s degree in Nursing or other clinical bachelor degree equivalent.
- Graduate from an accredited school of nursing or graduate from an accredited equivalent clinical program.
- 3+ years of documented direct management or supervisory experience in a clinical or managed care setting.
- 5+ years of clinical experience.
- 2+ years of utilization, quality or care management experience in an insurance or managed care setting.
- Formal education or training in supervision, management, or leadership and demonstrated experience in program planning, development and evaluation.
- Proven knowledge of the management, operation, function and objectives of population based utilization and care management services for individual patients/members.
- Expert customer service skills.
- Strong project management skills with the ability to coordinate complex projects and build work plans to lead a group through implementation and execution of new projects and continuous process improvement projects.
- Strong working knowledge of all pertinent regulatory and accrediting body requirements, specifically CMS, State Medicaid Programs, The Affordable Care Act and NCQA.
- Working knowledge of CPT, HCPCS and ICD-9 & ICD-10 coding.
- Demonstrated high level computer skills in MS Office Suite, Facets or other claims processing platforms, and Utilization Management or Care Management charting platforms
- Demonstrated working knowledge of health care cost containment concepts and managed care principles.
- Knowledge of medical benefits and medical/transplant network administration.
- Knowledge of confidentiality guidelines.
- Currently licensed as a registered nurse in good standing in Oregon or current equivalent clinical license.
- Master’s degree in Nursing, or related field.
- Certification in case management, utilization management or quality improvement.
- Project management, Six Sigma, Lean, Change Acceleration Process (CAP) experience or certification.
- Experience with HEDIS, CAHPS, Medicare 5-Star Rating, NCQA and/or URAC accreditation.