Job Summary:
The Manager, Utilization Management (UM) Strategy & Implementation leads a dedicated team that supports the UM program through multiple functions with a focus on all regulatory and compliance functions. This encompasses, but is not limited to, prior authorization analysis and filings, new business implementation, policy development, internal risk analysis, and audit and review preparation for the UM department. This role also manages cross-functional projects as needed to implement standardized/compliant processes across multiple lines of business and markets.
Essential Functions:
- Establish a baseline of compliance, regulatory and accreditation risk, identify areas of potential exposure, develop and align strategies for the department’s area of focus with CareSource goals and objectives and execute program ensuring consistency
- Proficient in current federal/state laws and regulations, industry standards and best practices around compliance, regulatory and accreditation requirements
- Oversee and manage UM Operations oversight functions such as Corrective Action Plan (CAP) management, ongoing monitoring, and multiple audit activities
- Build and leverage effective cross-functional business relationships and influence action across multiple internal and external partners to support a culture of compliance
- Responsible for development and maintenance of documentation related to policy, workflow and process when applicable
- Identify process gaps and drive improvements towards UM compliance in all areas
- Oversee and manage process changes across all teams in the department ensuring regulatory, accreditation and compliance business goals are met
- Maintain an in-depth knowledge of the company’s business, regulatory, compliance and accreditation environments and requirements
- Develop strategy and high-level implementation plans for the delivery of new business implementation, delegation implementation, product filings, regulatory, compliance and accreditation requirements
- Responsible for hiring, training, coaching, and developing direct reports including conducting performance reviews and disciplinary actions, as necessary
- Support all accreditation initiatives, including licensure applications, NCQA, and URAC
- Represent UM and clinical on market conduct exams or regulatory inquiries
- Monitor and analyze key compliance measures
- Collaborate with data and analytics, PH and BH clinical teams, compliance and regulatory to oversee and ensure regulatory reporting is timely and accurate
- Oversee and assist in the creation of the UM and clinical responses for the NQTL regulatory findings
- Serve as liaison between Clinical Operations, Regulatory, and Compliance Senior leadership
- Assure all departmental P&P’s and tools are reviewed at an appropriate cadence and contain required regulatory and accreditation related elements
- Report on status of departmental audit readiness and escalate to senior leadership if appropriate
- Collaborate with data analytics and research team on measurements and insight to ensure all key predictive measures are consistently reported and communicated
- Perform any other job related instructions, as requested
Education and Experience:
- Bachelor’s Degree in nursing or related field is required
- Master’s Degree in Business or health care field preferred
- Minimum of five (5) years clinical or related healthcare industry experience is required
- Prior leadership experience is required
- Managed Care experience is required
- Experience with analysis, data and reporting is required
- Accreditation, auditing, and process improvement experience is preferred
- Demonstrated change management and continuous improvement leadership skills are strongly desired
Competencies, Knowledge and Skills:
- Proficient use of Microsoft Office Suite, to include Word, Excel, PowerPoint, Outlook, and Visio with a strong willingness to learn
- Fluent in NCQA and/or CMS, accreditation and audit standards with knowledge of regulatory reporting, compliance requirements, and auditing procedures
- Decision making/problem solving and critical thinking skills
- Planning, problem identification and resolution skills
- Strong oral, written and interpersonal communication skills
- Energetic, enthusiastic and politically astute
- Responsive to a changing environment/change resiliency
- Proficiency with quality improvement, performance improvement and operations
- Ability to develop, prioritize and accomplish multiple competing goals
- Strong collaboration skills with ability to work with multi-disciplinary departments
- Ability to work independently and within a team
- Strong attention to detail and time management skills
- Customer service oriented with de-escalation skills
- Ability to gather/analyze data and create meaningful action items
- Ability to review and implement evidence-based trends
Licensure and Certification:
- Current, unrestricted Registered Nurse (RN) licensure is preferred
- Six Sigma or project management certifications are preferred
Working Conditions:
- General office environment; may be required to sit or stand for extended periods of time
Compensation Range:
$79,800.00 - $127,600.00
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer, including disability and veteran status. We are committed to a diverse and inclusive work environment.