Utilization Management Manager

2 weeks ago


Honolulu, Hawaii, United States AlohaCare Full time
Job Summary

AlohaCare is seeking a highly skilled Utilization Management Manager to join our team. As a key member of our healthcare operations team, you will be responsible for overseeing the utilization review activities, including the development and implementation of the Utilization Management Program (UMP).

Key Responsibilities
  • Manage the day-to-day operations of the UMP, ensuring that members receive care and services that meet all contractual and regulatory requirements for quality, timeliness, and access to care.
  • Supervise professional nursing staff performing utilization management functions for inpatient, outpatient, medical/surgical, behavioral health, and home and community-based services.
  • Work with Medical Directors to ensure availability of clinical guidance and support for clinical review staff.
  • Implement the UMP to ensure that members receive care in the least restrictive setting by overseeing the consistent application of appropriately approved clinical criteria guidelines.
  • Collaborate with the Quality Improvement (QI) department to ensure that quality care and services are provided to members in a timely manner.
Requirements
  • Licensed RN in the State of Hawaii.
  • A minimum of five (5) years of recent managed care, case management, utilization review, authorization process experience required.
  • A minimum of two (2) years of management experience.
  • Strong ability to function independently and coordinate the work of other personnel effectively.
  • Must be able to work as a team.
  • Must exhibit strong clinical, planning, organizational, and time management skills.
Preferred Qualifications
  • Three years inpatient clinical experience.
  • State regulatory experience.
  • URAC/NCQA and HEDIS exposure an asset.
Additional Job Requirements
  • Able to travel within area and occasionally out of area.
  • Ability to use Utilization Management software, MCG Criteria, Microsoft Office, CPT, and ICD-10 Manuals, AlohaCare Policy and Procedure.

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