Manager, Care Coordination

Position Summary

 

Responsible for daily operations of the Utilization Management department.  Evaluates and ensures all services originating in Utilization Management are of the highest quality.  Develops and implements policies to enhance the department?s performance and to maintain efficient workflow.  Maintains the department within budgetary guidelines.

 

General Responsibilities

 

? Responsible for daily operation of Utilization Management department including assignments, staffing and efficient workflow.

? Participate in the Care Improvement Plus Utilization Management Committee to promote effective communication, education, problem resolution and consistency of application of utilization/authorization criteria and function pertaining to Care Improvement Plus members.

? Serve as a resource for due diligence pre-contractual and annual audits for UM activities.

? Serve as a resource and or educator to the Physicians/Provider Medical Groups.

? Serve as a resource between UM staff of physicians to assist them with information that effectively expedites member access to the Linked and Carve Out Programs.

? Interface with Medical Director on Utilization Management activities (i.e. problem cases, need for Physician Advisor).

? Utilize monthly reports to assess ELOS the effectiveness of the Utilization Management activities.

? Identify the needs of the Utilization Management staff and assist in developing programs to address these needs.

? Monitor the UM staff and review daily activities.  Provide feedback to staff on a regular basis.

? Monitor all claims issues requiring Utilization Management determination.

? Recommends and facilitates new policies and procedures and guidelines to enhance the effectiveness of Utilization Management.

? Facilitate Utilization Management case conference of a daily basis with professional staff.

? Review potential Quality Assurance issues with the Medical Director and Utilization Management staff and attends all QOC meetings. 

? Provide a monthly report to the Director of Health Services outlining the Utilization Management department?s activities, productions, service levels, and personnel issues.

? Administers all reports required by regulatory agencies.

? Oversees the development of policies and procedures for the department.

? Provides leadership and assistance to staff in daily operations.

 

 

Required Education and Experience

 

?  Bachelor?s degree required

?  Active Maryland registered nurse license.

?  Minimum of five years of experience with acute inpatient nursing.

?  Minimum of two years working in a managed care environment.

?  Minimum of two years working in utilization or case management.

?  Minimum of five years of supervisory experience with increasing levels of responsibility.

 

Required Knowledge, Skills, and Abilities

?  Knowledge of Medicare, Medicaid and NCQA regulations preferred.

?  Maryland driver?s license with the ability to provide own transportation within the GSA.

?  Proficiency with MS Office Suite and Windows.

?  Excellent communication skills.

 

XLHealth and Care Improvement Plus are located in the beautiful downtown Camden Yards complex and surrounding areas. We offer a comprehensive benefits package including free on-site parking, a bonus pay program, company stock options, as well as an exciting entrepreneurial company environment.

Please submit resume and cover letter, including salary requirement, to the attention of the HR Generalist.
EOE/AA