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Manager of Utilization Review
3 months ago
The Manager of Utilization Review is responsible for managing a team of physical and/or behavioral health practitioners responsible for coordinating member service, utilization, access, care management and/or concurrent review to ensure cost effective utilization of health, mental health, and substance abuse services for one or more member product populations of varying medical complexity ensuring the delivery of essential services that address the total healthcare needs of members. Primary duties may include, but are not limited to:
- Manages and oversees team responsible in case finding and coordinating cases that involve comorbid conditions.
- Coordinates service delivery to include member assessment of physical and psychological factors.
- Partners with providers to establish short and long term goals that meet the member's needs, functional abilities, and referral sources requirements.
- Identifies members with potential for high risk complications.
- Reviews benefit systems and cost benefit analysis.
- Evaluates medical, mental health and substance abuse service for cost containment.
- Supports program compliance and assists in identifying opportunities to improve the customer service and quality outcomes.
- Supports quality initiatives and activities, including adherence to National Committee for Quality Assurance (NCQA) standards and HEDIS reporting.
- Hires, trains, coaches, counsels, and evaluates performance of direct reports.
Requirements
- BA/BS and minimum of 5 years of experience in Health Care Management; or any combination of education and experience, which would provide an equivalent background.
- Current active unrestricted RN, PA, LSW, LCSW, LPC, LMHC or other accepted license (as allowed by applicable state laws) and any other state or federal requirements that may apply is required.
- MSN, MPH, MPA, MSW or MBA with Health Care Concentration preferred.
- Certified Case Manager Certification preferred.
