Utilization Review Manager (RN - Hybrid)

Utilization Review Manager (Hybrid - Must live in Idaho)

• Are you an experienced Utilization Review Manager looking for a new challenge?
• Do you value care management and quality improvement?
• Are you motivated, energetic, and excited to become part of the Kepro team?

If so, you might be our next new team member!

Who we need:

The Utilization Review Manager is responsible for the management and oversight of Idaho Utilization Management Contract activities within clinical, contractual, and budgetary parameters.

Directs and oversees all clinical program activities to ensure overall consistency, thoroughness, and accuracy of the clinical programs. Directs program to ensure clinical efficiencies, deliverables and assigned contract functions are performed to the highest standards to strengthen the relationships with customers and meet contract requirements. Provides day-to-day oversight to manage the care management program and is responsible for overseeing the implementation of clinical contract requirements.

Why us?

Kepro is a rapidly growing national quality improvement and care management organization. We work to ensure that over 20 million people receive the right care, at the right time, in the right setting.

People Focused. Mission Driven.

Shape the future of healthcare with us. We are mission driven to improve lives through healthcare quality and clinical expertise.

We do this through our people.

At Kepro, you can do meaningful work that makes a real difference for the lives of individuals across the country. We are an organization that cares deeply about our employees and we provide the training and support to do the best work of your career.

Benefits are a key component of your rewards package at Kepro. These benefits are designed to provide you and your family additional protection, security, and support for both your career and your life away from work. They are comprehensive and fit a variety of needs and situations. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts and more.

What you’ll do:

• Responsible for UM reviews such as: genetic testing, surgeries/procedures, continued stay reviews, inpatient stays at Institutions for Mental Disease, Durable Medical Equipment, prosthetics, orthotics, and retrospective pre-payment reviews. NOTE**This list is not all-inclusive
• Advises and manages direct reports relative to their responsibilities for utilization management review and case management; including but not limited to operational standards and quality outcomes, regulatory and contractual compliance, policy and procedures and quality monitoring.
• Ensure compliance with contractual requirements within the clinical operation by monitoring critical indicators and adjusting processes to compensate for negative variances.
• Identify areas to improve operating efficiencies.
• Serve as a Subject Matter Expert (SME).
• Assists in achieving annual organizational priorities and operational indicators.
• Foster and maintain strong communications with staff through various means; e.g., one-on-one meetings, team meetings, and interdepartmental meetings.
• Provides oversight of contract activities including service level agreement metrics, processes, staff development, internal training, the quality of the review processes, effectiveness of the case management process, deliverables, and budgetary compliance.
• Responsible for clinical quality program to include auditing, Quality Improvement Plans (QIP’s) and administration of the Local Quality Improvement Committee.

The list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary from time to time.

• Clinical Reviewers (Registered Nurses, Social Workers, Licensed Professional Counselors)

What you’ll need:

Required Qualifications

• Active, unrestricted Licensed RN in Idaho or compact state
• Bachelor’s Degree or equivalent directly applicable experience in nursing, healthcare administration or related area is preferred.
• Must live in our around Boise, Idaho

Knowledge, Skills, Abilities

• Excellent verbal and written communication skills essential.
• Current working knowledge of utilization management, case management, and managed care.
• Customer-focused, results-oriented and capable of building and maintaining relationships with internal and external customers.
• Organizational skills, ability to plan and prioritize multiple assignments essential.
• Current Interqual and Milliman criteria knowledge
• Skill in examining and re-examining operations and procedures, formulating policy, and developing and implementing new strategies and procedures.
• Knowledge of U.S. healthcare industry
• Experience in using systems that support Utilization and Case Management processing
• Demonstrated expertise in managing differing customer needs.
• Understanding of URAC standards and processes
• Ability to participate as a team member fostering collaborative decision-making among leadership, committees, teams or work groups of diverse composition.
• Computer proficiency in Microsoft Office applications and other software programs essential to perform job functions
• Ability to develop, plan, and implement short-and long-range goals.
• Skill in employee development and performance management.
• Ability to provide technical guidance and leadership to management team.
• Advanced verbal and written communication skills and the ability to work with a wide range of constituencies in a diverse community.

Experience

• Significant experience managing clinical care management (UM) operations, at least 2 years of clinical management experience required

• 3 years of utilization review experience preferred.

Thank You!

We know your time is valuable and we thank you in advance for applying for this position. Due to the high volume of applicants we receive, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Kepro and invite you to apply to future openings that may be of interest. Best of luck in your search!

~ The Kepro Talent Acquisition Team

Mental and Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations will be made as required by law in an attempt to enable an individual with a disability to perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time; key and/or control objects; interact extensively with internal and external customers; occasionally lift and/or move objects weighing up to 10 pounds; and occasionally travel within the state.

EOE AA M/F/Vet/Disability

Kepro is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.