Utilization Management Clinical Manager

Summary

Join Integra Partners as a Utilization Management Clinical Manager RN and oversee the daily operations of the Utilization Management department. You will develop and implement new programs, ensure regulatory compliance, and maintain quality of care. Provide leadership and guidance to the team, collaborating with other departments for timely utilization management decisions. This role reports to the Director of Utilization Management and requires a BSN, RN licensure, and significant experience in utilization management within a managed care environment. Integra Partners offers a competitive compensation package including benefits such as health insurance, paid time off, retirement plan, and remote work opportunities.

Requirements

• Active, unrestricted Registered Nurse
• Bachelor's degree in nursing (BSN)
• Registered Nurse (RN) licensure
• Minimum of 3 years of nursing in an acute or outpatient setting
• Minimum of 5 years of UM experience in a managed care, payor environment
• Experience with New York Medicare and Medicaid
• Knowledge of regulatory requirements related to utilization management, such as CMS and NCQA standards
• Strong communication, leadership and analytical skills
• Ability to work effectively in a fast paced, team-oriented environment
• Proficiency in Microsoft Office application and health plan systems
• Experience with Medicare, Medicaid UM authorizations and appeals for DMEPOS
• Experience with Medical Necessity Criteria including but not limited to InterQual, CMS guidelines, health plan medical policies, etc
• Verbal and written communication skills to convey information clearly and consistently

Responsibilities

• Oversee the day-to-day operations of the Utilization Management department, including staffing, scheduling, etc
• Ensure that the department meets all regulatory requirements
• Maintain the quality of care provided by the department
• Provide leadership and direction to the team of LPNs, RNs, and utilization management coordinators
• Conduct performance reviews and provide feedback to staff
• Develop and implement training programs for staff
• Represent the department to other departments and stakeholders
• Ensure timely and accurate utilization management decisions
• Establish and maintain effective working relationships with health plan providers, including payers, physicians, and other providers
• Monitor and analyze utilization management data to identify trends and opportunities for improvement
• Develop and implement utilization management programs to improve quality and cost-effectiveness of health plan services
• Collaborate with other departments, such as Quality and Provider Relations, to identify and address utilization management issues
• Participate in internal and external audits of the utilization management process
• Maintain compliance with all accrediting agency standards such as NCQA, CMS and State agencies
• Performs other duties as assigned

Preferred Qualifications

• Strong organizational skills, ability to adapt quickly to change and desire to work in a fast-paced environment
• Team oriented and self-motivated with a positive attitude

Benefits

• Competitive compensation and annual bonus program
• 401(k) retirement program with company match
• Company-paid life insurance
• Company-paid short term disability coverage (location restrictions may apply)
• Medical, Vision, and Dental benefits
• Paid Time Off (PTO)
• Paid Parental Leave
• Sick Time
• Paid company holidays and floating holidays
• Quarterly company-sponsored events
• Health and wellness programs
• Career development opportunities
• Remote Opportunities