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.
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.
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 (2+ years preferred).
Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
Licenses/Certifications: Current state’s nursing license, or ability to obtain.