Responsible for managing the activities of the Utilization and Case Management Departments. Provides leadership in the development of a culture for quality care. Performs highly responsible management work in leading, developing, directing, and coordinating programs and functional activities. Establishes tools, processes, and systems to optimize clinical quality, patient safety and care management.  Responsible for measuring quality as well as identifying opportunities and strategies for clinical performance improvement. Carries out all duties while maintaining compliance and confidentiality and promoting the mission and philosophy of the organization. 

ESSENTIAL DUTIES AND RESPONSIBILITIES 

• Generates, implements and maintains the annual Utilization Management Program, Case Management Programs and Disease Management Programs.

• Maintains staffing at a level adequate to meet the needs of our business, and provides consistent training, auditing, and feedback

• Consistently meets or exceeds standards regarding:

• Prior authorization requests (routine, urgent or emergent, etc.)

• Denials, appeals, and complaints

• Telephone statistical reporting

• Maintains Utilization Review Agency licensure

• Develops, monitors, and updates policies and procedures regarding utilization management programs in accordance with State and Federal law

• Responsible for identifying and implementing new technology to assist in the timely and accurate payment of claims (e.g., coding software, imaging and archiving solutions, etc.)

• Provides management direction to the functional area of case management; provides direction to staff in carrying out responsibilities; interprets laws, policies, operational procedures, and objectives; reviews operations in assigned area to ensure high level of quality is consistent with organizational standards. 

• Responsible for collecting, analyzing, evaluating, and presenting utilization management, case management and disease management data to a wide range of audiences. 

• Promotes the effectiveness of support systems structure and infrastructure for assigned area of accountability. 

• Performs operations analysis with appropriate follow-up action plan and intervention. 

• Promotes decision-making in area of responsibility, utilizing processes and interactions promoting information analysis of all involved factors relative to corporate strategy and position. 

• Applies Human Resources/Personnel policies per organizational procedure and serves as resource for the implementation of such policies and procedures; defines expectations for performance and holds subordinates accountable; sets goals and outcome parameters and defines operational parameters and expectations. 

• Establishes planning processes in response to corporate strategy, goals, and objectives; monitors on a regular basis progress and accomplishments; promotes and coordinates program development through appropriate planning, analysis, and developmental phases. 

• Collaborates with administration, management, and educational resources to develop mechanisms for educational advancement; facilitates methods for professional development consistent with the demands of the position in an effort to assure competency in assigned area of responsibility; plans strategy for development and ongoing educational needs; serves as mentor (coach and counsel) promoting professionalism on a group or individual basis. 

• Directs the development of systems and mechanisms to monitor the effectiveness and improvement of professional interventions. 

• Reviews department performance in relation to established goals, implementing changes to effect continual improvement in services provided; and ensures compliance with regulatory and legal requirements. 

• This position assumes and performs other duties as assigned.

 

QUALIFICATIONS  

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions:

• Superior knowledge of utilization management guidelines, plan benefit design, and medical necessity criteria

• Knowledge of health care delivery systems, statistical review skills, and data management skills

• Knowledge of ambulatory and inpatient utilization patterns/efficiency

• Demonstrable skills in successful team building and managing for agreement

• Knowledgeable of State of Texas Department of Insurance (TDI) regulations, TDH and federal regulations governing claims payment, and HIPAA regulations.

• Excellent verbal and written communication skills.

• Strong computer skills including working with Microsoft Access and Excel applications.

• Ability to communicate with all levels of staff including physicians and Executive Management.

• Required to manage laterally and upward, as well as downstream.

 

EDUCATION and/or EXPERIENCE 

• At least five (5) years of experience in utilization management and/or case management (managed care experience preferred).  Additional background in health care delivery systems, statistical review skills, and data management skills preferred.

• Bachelor's degree (B. A.) from four-year college or university; or one to two years related experience and/or training; or equivalent combination of education and experience.

CERTIFICATES, LICENSES, REGISTRATIONS 

• Registered Nurse with current Texas license in good standing; BSN preferred.

• Certified Case Manager

WORK ENVIRONMENT  

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• While performing the duties of this Job, the employee is regularly required to sit; use hands to handle or feel; talk; and hear. 

• Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

• The noise level in the work environment is usually:   Mild         

• For this position the percentage of expected Travel is: 5% of the time