Director, Utilization Management

Location: Indianapolis, IN
Joining this team means you'll be surrounded by colleagues who are dedicated to meeting their own high standards, to inspiring their teammates and to making a positive impact on under-insured and uninsured individuals. The group is a fast, agile, customer-focused organization with a commitment to implementing the latest technologies.
 
Our client serves more than 55 million managed care members through their portfolio of high-quality commercial and government sponsored healthcare programs. The broad offering of programs that they provide has helped them to build both capacity and capability to successfully navigate a changing healthcare environment, while continuing to offer better health outcomes at lower costs.
 
Position Purpose:
Oversee operations of the referral management, telephonic utilization review, prior authorization functions, and case management programs. Ensure compliance government and contractual guidelines and the mission, philosophy and objectives of Corporate and the health plan.
 
Job Description:
  • Oversee the operations of the referral management, telephonic utilization review, prior authorization, and case management functions.
  • Support and perform case management, disease management and on site concurrent review functions as necessary.
  • Provide support to Provider Relations issues related to Utilization issues for hospitals and physician providers.
  • Coordinate efforts with the Member Services and Connections Departments to address members and providers issues and concerns in compliance with medical management requirements.
  • Maintain compliance with National Committee for Quality Assurance (NCQA) standards for utilization management functions for the prior authorization unit.
  • Develop, implement and maintain policies and procedures regarding the prior authorization function.
  • Identify quality and risk management issues and facilitate the collection of information for quality improvement and reporting purposes.
  • Compile and review multiple reports for statistical and financial tracking purposes to identify utilization trends and assist in financial forecasting.
 
Qualifications:
Education/Experience:
  • Bachelor's degree in Nursing or equivalent experience.
  • 5+ years of nursing experience in an acute care setting or medical/surgical, pediatrics, or obstetric in a managed care environment.
  • 1+ years of utilization management and/or case management experience.
  • Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
 
Licenses/Certifications:
  • Indiana RN – Registered Nurse
 
Our client offers options that allow you to do more than just plan for retirement. Their programs allow shared success with employees.
  • 401(k) with company match
  • Employee stock purchase plan
  • Training and Learning Opportunities/Tuition Reimbursement/Educational Assistance
  • On-site fitness center or discount at local fitness centers (most locations)
  • Discounts for select local and national products and services, including cell phones, computers and more
  • Other amenities may be available, but vary by location
 
Equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
 
 
 
April A. Estes
Senior Recruiter
720-439-2609 Direct
april@proenlist.com 
www.proenlist.com 
www.medenlist.com 

www.linkedin.com/in/aprilaestes
 
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