Clinical Operations Manager
4 weeks ago
Clinical Effectiveness Unit Overview
Commonwealth Care Alliance's (CCA) Clinical Effectiveness Unit plays a crucial role in evaluating the medical necessity, appropriateness, and efficiency of healthcare services, procedures, and facilities under CCA's benefits plan.
The Manager, Utilization Management oversees and manages the daily operation of the Utilization Management Review Nurse and Specialist staff responsible for conducting centralized clinical review and authorization creation for centrally-authorized services.
This position has a key role in ensuring CCA meets CMS compliance standards in the area of service decisions and organizational determinations.
Key Responsibilities
- Oversees clinical decision review for services requiring prior authorization in a variety of clinical areas
- Ensures timely and accurate communications of medical necessity review results to the original requester
- Manages the process for escalated reviews in accordance with Standard Operating Procedures
- Liaises with clinical teams and re-insurer on high-cost cases
- Ensures that department and organizational policies and procedures as well as regulatory and contractual requirements are met
- Tracks and monitors team's performance against targets
- Investigates and resolves member complaints and grievances related to relevant services and supports
- Conducts audits and performs quality assurance
Requirements
- Associate's Degree in Nursing, Bachelor's Degree preferred
- 3-5 years utilization management experience required
- 3+ years experience working in a health plan, specifically with utilization management required
- 3+ years of management experience preferred
- Will be required to pass CCA's credentialing process
- Demonstrated ability to establish and manage performance and outcome metrics
- Strong project management skills with the demonstrated ability to handle multiple projects
- Ability to establish and maintain positive and effective work relationships with internal staff, external vendors, and state and federal agencies
- Excellent organizational, time-management and problem-solving skills
- Strong management skills
- English required, bilingual preferred
Equal Opportunity Employer
Commonwealth Care Alliance is an equal opportunity employer and welcomes applications from diverse candidates.
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