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Alliance Health · 5 days ago

Supervisor - Utilization Management Physical Health (Full Time, Remote, North Carolina Based)

United States

Full-time

Remote

Senior Level

$89K/yr - $114K/yr

5+ years exp

Alliance Health is seeking a Supervisor – Utilization Management Physical Health to oversee all aspects of Utilization Management related to physical health authorizations and quality improvement activities. The role involves training and coaching staff, ensuring compliance with policies, and collaborating with various departments to enhance service delivery.

Health Care

Responsibilities

Implement unit goals and objectives

Integrate the department and its functions into the organization’s primary mission

Ensure the Utilization Management Department serves as an integrated department through effectively collaborating with Behavioral Health counterparts

Work with Human Resources and Unit Director to maintain and retain a highly qualified and well-trained workforce

Ensure staff are well trained in and comply with all organization and department policies, procedures, business processes and workflows

Ensure the department has the needed tools and resources to achieve organizational goals and to support employees and ensure compliance with licensure, regulatory, and accreditation requirements

Actively establish and promote a positive, diverse, and inclusive working environment that builds trust

Ensure all staff are treated with respect and dignity

Ensure standards are transparent and applied consistently, impartially, and ethically over time and across all staff members

Work to resolve conflicts and disputes, ensuring that all participants are given a voice

Set goals for performance and deadlines in line with organization goals and vision

Effectively communicate feedback and provide ongoing coaching and mentoring to staff and support a learning environment to advance team skills and professional development

Cultivate and encourage efforts to expand cross-team collaboration and partnership

Ensure consistent application of medical necessity criteria for physical health services that promotes a holistic review of the member’s needs

Ensure compliance with performance measures outlined within NC DHB, NC DMH contracts and all accrediting body standards

Monitor systems that ensure the authorization of services provided by clinical care staff appropriately address the service needs, types of service, outcomes, and alternatives available to consumers

Provide education to hospitals, nursing homes and other care providers concerning departmental procedures and requirements for approving length of stay extensions

Perform other related duties as required by the immediate supervisor or other designated Alliance Health administrators

Analyze and monitor community capacity for service needs, service gaps, and the implementation of evidence based/best practices

Review and Revise department Desk Manual as needed

Complete mediations for denial or reduction of Physical Health Medicaid services completed by Alliance Health

Represent Utilization Management determinations for Physical Health services in court as requested by legal counsel

Assess and improve the department’s performance based on established indicators and outcomes

Attend federal, state and local meetings as agency liaison

Ensure authorized services address appropriate service needs, intensity of service outcomes, and alternatives for consumers

Support Sr. UM Director and UM Directors in reporting data and quality metrics

Maintain accessible and close working relationships with all applicable department heads and decision makers to develop a more coordinated and streamlined service delivery system for individuals and families throughout the service area

Identify opportunities for collaboration on inter-departmental projects that reduces duplication and inefficiencies across the system

Works with the Medical Directors with decision making of medical necessity cases, specialists, and primary care physicians

Coordinate and integrate services within the department and with other departments

Develop and maintain open timely communication with staff, providers, community agencies and other stakeholders

Qualification

Utilization ManagementRegistered Nurse LicenseClinical Practice KnowledgeWorkflow DevelopmentAcute Clinical Utilization ReviewLeadership AbilitiesNCQA ExperienceSoftware ProficiencyCommunication SkillsProblem Solving

Required

Graduation from an accredited Nursing school and (5) years of experience in Utilization Management or substantially equivalent experience

Bachelor's degree from an accredited college or university in Nursing and three (3) years of experience in Utilization Management or substantially equivalent experience

Must have a current, active, unrestricted North Carolina license as a Registered Nurse

Must be knowledgeable in Utilization Management managed care principles and strategies

Knowledge of physical health and co-morbid health conditions

Knowledge of diagnostic treatment guidelines/protocols, level of care criteria

Authorization/re-authorization Utilization Management standards

Ability to develop and document workflows

Written and oral communication skills

Ability to analyze effectiveness of processes and make adjustments to developed processes

Experience in acute clinical utilization review

Experience in related duties in the delivery of patient care, management of patient care providers, or project management in a healthcare environment

Demonstrates ability to interact with a wide variety of individuals, and handle complex and confidential sensitive situations

Able to lead, delegate and problem solve