Lead the respective managers and teams in the ongoing internal and external health services operations as related to Utilization Management process.
Responsible for utilization management across all Lines of Business (LOBs). Facilitate, guide, create, and monitor data and relevant analytics for ongoing operations and regulatory oversight bodies. Participate and prepare appropriate materials for relevant committees and oversight bodies. Promote and oversee audit processes and assist in identification and resolution of gaps. Lead the staff and processes to effectively improve our customer service and provides leadership and direction to our team through the promotion and training of LEAN project management. Work collaboratively with internal and external community entities and in the implementation of quality improvement measures and process transformation initiatives.
Work Experience: At least seven years of experience with varied medical exposure required. Minimum of 3 years management or supervisory experience required. Experience with Medicaid and Medicare clinical operations in health plans is required. Experience in case management, disease management, utilization management and program development using evidence based medicine required. Experience in Medicare bid process and benefit design is preferred. Prior success in healthcare integration, process development and program implementation is desirable. Additional experience managing complex work processes, including, HEDIS, 5 Star and HCC related projects is highly preferred.
Education, Certificates, Licenses: Bachelor degree in health services administration or related field required. Registered nurse with current unrestricted state license required. Maintains current clinical knowledge base and specialty nurse functions. Certified Case Manager (CCM) as accredited by CCMC (The Commission for Case Management Certification), or equivalent.
Knowledge: Knowledge and understanding of disease prevention, medical procedures, care modalities, procedure codes (including ICD-10 and CPT codes,), health insurance, and CMMS / State of Oregon mandated benefits. Ability to develop, review, and evaluate utilization reports. Knowledge of and demonstrated experience with quality improvement methodology. Experience giving presentations. Organizational skills with solid experience in using computers and various software applications including Microsoft Office Suite, SharePoint, Claims and Care management programs, and audio-visual equipment. Ability to work independently with minimal supervision. Ability to deal with members, patients and families at all levels of care and/or crisis. Thorough knowledge of community services, providers, vendors and facilities available to assist members. Ability to supervise and manage a regular staff and a professional nursing staff. Continually seeks to improve quality of service, care, and processes for internal and external customers.
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 30% of the time.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.