Utilization Management Team Leader

We are seeking an experienced Utilization Management Team Leader for our Health Services Department at our Nashville location.

 

The Utilization Management Team Leader will be responsible for assisting the Manager/Director/VP and Medical Director in the development, implementation, and management of utilization management functions, including concurrent review, and retrospective review.  Provides direct supervision for the daily operations of the utilization management IP personnel involved in these operations.  Supports provision of high quality, cost-effective clinical care in efficacious relationships with health care providers.  The Team Leader oversees the stewardship of medical resources by assuring appropriate utilization.  Effectively channels utilization to high quality, cost-effective providers, in the most appropriate level of care clinical setting.  Provides effective human resources management.

 

Responsibilities include:

? Provides daily guidance and supervision to health plan IP personnel in operating effective utilization management functions

? Implements utilization management processes according to department policies and procedures

? Responds to medical service questions in a timely manner

? Integrates case management/disease management program into utilization management  functions as appropriate

? Assists in achieving department goals and objectives

? Serves as department utilization management representative in community/professional committees

? Evaluates the utilization management program and strategic planning for area of responsibility

? Manages operation of concurrent review and retrospective review programs for onsite IP activities

? Assures that medication action plans are well conceived, targeted appropriately, and executed effectively

? Educates utilization management personnel on DRG, contract logic, coordination of benefits and subrogation to maximize reimbursement

? Assists Grievance and Appeals Coordinator in the retrospective review of medical records and claims for medical necessity for IP

? Monitors process and outcomes through ongoing case review and implements action plans to improve quality and minimize risk

? Maintains efficacious working relationships with healthcare providers

? Analyzes utilization patterns to identify aberrations and develop/implement corrective action plans

? Supports and participates in physician, hospital, and ancillary provider education

? Assists in monitoring the provider network needs and makes recommendations for changes

? Effectively utilizes established guidelines in implementing utilization management functions

? Creates and maintains internal and external customer focus

? Assists Manager/Director/VP and Medical Director in meeting any required regulatory and/or oversight accreditation standards

? Has in in-depth understanding of the transactional system and oversees timely and correct case data entry to ensure correct IP statistics

? Assists Manager/Director/VP in recruitment of high-quality staff

? Maintains staff morale and staff retention

? Assists Manager/Director with weekly staff meetings

? Resolves performance issues in a timely and sensitive manner

? Actively participates in professional development activities through continuing education and management development programs

? Conducts orientation of all new personnel

? Assists the Director and Medical Director in tasks as assigned

 

Supervisory Responsibilities:Assists Manager/Director with hiring, managing, and evaluating IP utilization management personnel

 

 Job Related Skills:Communicates information accurately and timely to internal and external staff.  Written and oral communication is accurate and timely and at the appropriate levelAbility to articulate clinical and non-clinical information to personnel of all levels of understandingAbility to communicate with team members at all levels and in a positive mannerAssists education of internal staff in medical management operations, policies and procedures, and protocols that pertain to authorization, concurrent review and retrospective reviewAbility to analyze data to identify significant trends and opportunities for improvementAbility to handle multiple tasks, set priorities, and develop action items.  Detail oriented.Knowledge of regulatory requirements with emphasis on MedicareExtensive knowledge of systems in the area of relational database, Internet, Excel and word-processingExperience in internet/web searches for clinical information and industry standardsStrong management/supervisory/problem-solving skills required

 

Requirements Include:

? Registered Nurse with a Bachelor?s/Master?s degree in nursing, health administration, or related field

? Nursing license in the State of Tennessee

? 5-7 years clinical nursing experience

? 3 years experience in managed care or related work in Health Services with emphasis on education, protocol development, and administration.  Management experience preferred.

 

HealthSpring of Tennessee offers a competitive salary and a full range of benefits.

 

To be considered, visit http://healthspring.mywebinterview.com/app/TN to complete an online application.

 

Select Department:  Health Services

Select Position: Utilization Management Team Leader

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