Clinical Utilization Management Specialist
1 month ago
Vivo HealthStaff is seeking a highly skilled Clinical Utilization Management Specialist to join our team. This role is crucial in ensuring a streamlined and compliant denial process, aligning with regulatory, accreditation, and health plan standards.
Key Responsibilities- Oversee denial unit staff, managing daily tasks, performance reviews, and disciplinary actions.
- Foster effective communication and collaboration with physician reviewers, medical directors, and other departments.
- Ensure timely responses to requests and maintain high standards of compliance and privacy.
- Assist in preparing reports, including departmental work-plans and audits.
- Monitor and enhance the quality of the denial process internally.
- Design and deliver training sessions for denial unit staff.
- Stay updated with state and federal regulations related to the department and implement necessary changes.
- Lead the department towards achieving set objectives and provide guidance to team members.
- Implement procedures to ensure alignment with company policies and influence process improvements.
- Graduate from an accredited Registered Nursing Program; RN preferred.
- Minimum of five years in prior-authorization, appeals & grievance, or health plan compliance.
- Proven experience in project development, staff supervision, and performance monitoring.
- Strong communication skills, both verbal and written.
- Ability to manage multiple projects in a high-stress environment and adapt to changing priorities.
- Proficiency in MS Office and a computerized environment.
- Valid CA driver's license and car insurance.
- Uphold honesty and integrity.
- Adhere to privacy, compliance policies, and the corporate code of conduct.
- Lead and participate in team meetings and promote organizational goals.
- Provide top-tier customer service and be adaptable to flexible work hours.
- Comprehensive healthcare coverage.
- Competitive 401k plan.
Vivo HealthStaff is a healthcare staffing and recruitment firm based in the San Francisco Bay Area, providing permanent and temporary opportunities to organizations across the United States.
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