Utilization Management Director leads and directs the utilization review staff and function for a healthcare facility. Determines policies and procedures that incorporate best practices and ensure effective utilization reviews. Being a Utilization Management Director manages and monitors both concurrent reviews to ensure that the patient is getting the right care in a timely and cost-effective way and retrospective reviews after treatment has been completed. Provides analysis and reports of significant utilization trends, patterns, and impacts to resources. Additionally, Utilization Management Director consults with physicians and other professionals to develop improved utilization of effective and appropriate services. Requires a master's degree. Typically reports to top management. Typically requires Registered Nurse(RN). The Utilization Management Director manages a departmental sub-function within a broader departmental function. Creates functional strategies and specific objectives for the sub-function and develops budgets/policies/procedures to support the functional infrastructure. Deep knowledge of the managed sub-function and solid knowledge of the overall departmental function. To be a Utilization Management Director typically requires 5+ years of managerial experience. (Copyright 2024 Salary.com)
Apply on line at http://www.alohacare.org/Careers/Default.aspx
The Company:
AlohaCare is a local, non-profit health plan serving the Medicaid and Medicare dual eligible population. We provide comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers. Our mission is to serve individuals and communities in the true spirit of aloha by ensuring and advocating access to quality health care for all. This is accomplished with emphasis on prevention and primary care through community health centers that founded us and continue to guide us as well as with others that share our commitment. As Hawaiis third-largest health plan, AlohaCare offers comprehensive prevention, primary and specialty care coverage in order to successfully build a healthy Hawaii.
The Culture:
AlohaCare employees share a passion for helping Hawaiis most underserved communities. This passion for helping and caring for others is internalized and applied to our employees through a supportive and positive work environment, healthy work/life balance, continuous communication, and a generous benefits package.
AlohaCares leadership empowers and engages its employees through frequent diversity, recognition, community, and educational events and programs. AlohaCare has a strong commitment to support Hawaiis families and reinforces a healthy work/home balance for its employees. Because AlohaCare values honesty, respect and trust with both our internal and external customers, we encourage open-door, two-way communication through daily interactions, employee events and quarterly all-staff meetings. AlohaCares comprehensive benefits package includes low cost medical, dental, drug and vision insurance, PTO program, 401k employer contribution, referral bonus and pretax transportation and parking program.
These employee-focused efforts contribute to a friendly, team-oriented culture which is positively reflected into the communities we serve.
The Opportunity:
Job Summary:
The primary responsibility of the UM Review Nurse is to conduct prior authorizations and concurrent reviews, using proprietary or online tools for medical necessity and documentation systems that integrate service requests, care management, and claims. The nurse will work collaboratively with the Medical Directors to implement medical policies and guidelines that are consistent with MedQUEST, Medicare, and NCQA requirements. The UM Review Nurse fosters a team culture of interdependency, efficient workflows, new learning, adaptability to change, critical thinking, compliancy, and professional provider communication. Cost-effective member access to clinical or health services is paramount in the UM Review Nurses daily activities. By behavior and work style, the UM Review Nurse communicates, coordinates, and collaborates with other AlohaCare staff or external parties that result in outstanding utilization management of members and their providers.
Primary Duties, Responsibilities and Competencies:
Job Qualifications & Requirements
Required Competencies and Qualifications:
Preferred Qualifications
Mental, Physical and Environmental Demands:
Salary range: $70,000 - $85,000 annually
AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veterans status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.
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