Managed Care facility Services (HCS) works with members, providers, and multidisciplinary team members to assess, facilitate, plan, and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.
The Utilization Manager, Healthcare Services provides operational management and oversight of integrated Healthcare Services (HCS) teams responsible for providing Managed Care facility members with the right care at the right place at the right time and assisting them to achieve optimal clinical, financial, and quality of life outcomes.
Responsible for clinical teams (including operational teams, where integrated) performing one or more of the following activities: care review/utilization management (prior authorizations, inpatient/outpatient medical necessity, etc.), case management, transition of care, health management and/or member assessment. Typically, through one or more direct report supervisors, facilitates integrated, proactive HCS management, ensuring compliance with state and federal regulatory and accrediting standards and implementation of the Managed Care facility Clinical Model. Manages and evaluates team member performance; provides coaching, counseling, employee development, and recognition; ensures ongoing, appropriate staff training; and has responsibility for the selection, orientation, and mentoring of new staff. Performs and promotes interdepartmental/ multidisciplinary integration and collaboration to enhance the continuity of care including Behavioral Health and Long-Term Services & Supports for Managed Care facility members. Oversees Interdisciplinary Care Team meetings. Functions as hands-on manager responsible for supervision and coordination of daily integrated healthcare service activities. Ensures adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and other performance indicators. Collates and reports on Care Access and Monitoring statistics including plan utilization, staff productivity, cost-effective utilization of services, management of targeted member population, and triage activities. Ensures completion of staff quality audit reviews. Evaluates services provided and outcomes achieved and recommends enhancements/improvements for programs and staff development to ensure consistent cost effectiveness and compliance with all state and federal regulations and guidelines. Maintains professional relationships with provider community, internal and external customers, and state agencies as appropriate, while identifying opportunities for improvement.
Registered Nurse or equivalent combination of Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) with experience in lieu of RN license. OR Bachelor's or master’s degree in Nursing, Gerontology, Public Health, Social Work, or related field.
5+ years of managed healthcare experience, including 3 or more years in one or more of the following areas: utilization management, case management, care transition, and/or disease management. Minimum 2 years of healthcare or health plan supervisory or managerial experience, including oversight of clinical staff. Experience working within applicable state, federal, and third-party regulations.
3+ years supervisory/management experience in a managed healthcare environment. Medicaid/Medicare Population experience with increasing responsibility. 3+ years of clinical nursing experience.
Preferred License, Certification, Association
Certifications: Any of the following:
Certified Case Manager (CCM), Certified Professional in Healthcare Management Certification (CPHM), Certified Professional in Health Care Quality (CPHQ), or other healthcare or management certification.