JOB SUMMARY:

Responsible for managing clinical and nonclinical team members. May oversee complex case management, concurrent review, prior authorization, call center and or letter teams. Identifies, implements, and evaluates relevant performance metrics that allow for objective evaluation of staff and/or departmental performance.

Responsible for monitoring and facilitating the attainment of performance metrics to meet departmental expectations for productivity and quality. Responsible for managing staffing requirements for daily workload and auditing of letters to comply with all regulatory requirements.

Complete deliverables within established timelines. Responsible to ensure the auditing of staff monthly, and as needed to maintain compliance with state, federal and accreditation requirements. Facilitates clinical rounds and recommends training as needed.

Ensures that organizational and departmental goals, as identified in Department's annual Business Plan, including specific departmental process improvement plans are met. Serves as the subject matter expert for assigned line of business. Acts as a department liaison/project manager on initiatives where collaboration is required for departmental and organizational goal attainment. In collaboration with the UM trainer (s) is responsible for staff onboarding. Responsible for staff development and performance management. Trouble shoots and investigates authorization issues as needed. Manages the staffing needs by reviewing analytic reports for productivity, pended cases, and average admissions per facility etc. Participates in workgroups across the organization and makes recommendations for improvement.

Complete deliverables within established timelines. Actively foster and engage in efforts to ensure a culture of collaboration and teamwork within Community's Leadership as well as with all internal and external partners. Supports organizational goals as outlined in the program description. Demonstrates Harris Health and Community Health Choice values, including trust, integrity, mutual respect, diversity, responsiveness and caring service. Complete other duties as assigned by the Director of Utilization Management and SVP Medical Affairs.

MINIMUM QUALIFICATIONS:

Education/Specialized Training/Licensure:

RN required, bachelor's degree in nursing (BSN) preferred.

Current, unrestricted license in the state of Texas,

Master of Business Administration (MBA), Master of Health Administration (MHA) and/or Master of Science in Nursing (MSN) preferred.

Experience in Medicaid and/or Commercial lines of business

Work Experience:

Understand the Utilization Review process including census management.

Experienced with medical necessity guidelines including MCG guidelines and/or InterQual guidelines
3-5 years of managed care experience

Management Experience:
3-5 years of supervisory or leadership experience.

Equipment Operated: Moderate level of computer knowledge with word, excel, outlook, PowerPoint and access data bases.

Advanced Education:

Advance Training Specialty: CCM preferred
Bachelor's Degree Major: BSN preferred.

Work Schedule: Remote with mandatory attendance for department meetings and company townhalls.

Other Requirements: Ability to work autonomously, self-motivated, critical thinker, solution oriented, ability to perform at a high level under pressure and short deadlines.

RESPONSIBLE TO: Director Utilization Management