Manager, Utilization Management

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We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, , IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only).

Our Department of Defense contract requires U.S. citizenship and a favorably adjudicated DOD background investigation for this position.

Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Manages prospective and concurrent Utilization Management (UM) programs including prior authorization, concurrent inpatient and continued stay reviews including authorization and management of selected post inpatient care. This position reports to the Director of UM and coordinates with Case Management (CM) and Care Coordination (CC) Managers. The position is responsible for providing assistance with the development of UM desk procedures, training, auditing and implementing UM program policies consistent with contractual and performance management goals.

• Registered Nurse with current, unrestricted license for appropriate state (RN)
• 5 years’ experience in a clinical setting
• 2 year experience with a managed care program
• 3 years supervisory or management leadership experience in a healthcare environment

• Commercial Managed Care experience
• Master's Degree in Nursing or related field
• Veterans Healthcare or TRICARE Program experience
• Experience with policy development and technical writing
• Experience in budgeting, strategic program management and staff development

• Provides leadership to ensure operational effectiveness and efficiency of prospective and concurrent UM including discharge planning activities to meet and exceed production and service-level goals.
• Provides coaching and oversight to staff to ensure staff success and development.
• Oversees the program quality assurance and quality improvement processes related to UM programs.
• Generates reports to identify trends and opportunities for process improvement.
• Facilitates efforts to enhance UM programs by working collaboratively with the UM Director and other Medical Management leaders to effectively manage contract and internal performance standards.
• Provides assistance with Desk Procedures (DP) development monitors and provides assistance with application use and training programs in support of DPs.
• Collaborates with Data Management staff for data compilation and statistical analysis regarding program outcomes.
• Develops audit reports to identify quality issues and to identify areas for enhanced staff training.
• Develops new training programs, training documents, and flow diagrams to address targeted operational issues.
• Collaborates with clinical leadership to implement new processes for enhancing service levels.
• Assists the UM Director with staffing projections for contract management and budgets.
• Performs other duties as assigned.
• Regular and reliable attendance is required.

• Communication / People
  
  Skills:
  
  Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.
• Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, Tri West Intranet, the Internet, and department software applications.
• Delegation
  
  Skills:
  
  Provide clear performance expectations for projects and ensure adequate access to resources for completion.
• Independent Thinking / Self‑Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources.
• Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions.
• Leadership: Successfully manage different styles of employees; provide clear direction and effective coaching.
• Multi‑Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment.
• Organizational
  
  Skills:
  
  Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources;…