PA Health & Wellness · 1 day ago
Supervisor, Utilization Management
United States
Full-time
Remote
Mid, Senior Level
$75K/yr - $135K/yr
4+ years expPA Health & Wellness is a diversified national organization seeking a Supervisor for their Medical Management/Health Services team. The role involves supervising the utilization management team to ensure appropriate care for members, monitoring compliance with standards, and collaborating with senior management to improve processes.
FitnessHealth CareWellness
Responsibilities
Lead inpatient concurrent reviews for the California market and supervise the CCRN team, ensuring accurate, timely, and compliant UM decisions
Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards
Collaborates with utilization management team to resolve complex care member issues
Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management
Works with utilization management team and senior management to identify opportunities for process and quality improvements within utilization management
Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers
Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures
Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services
Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones
Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards
Assists with onboarding, hiring, and training utilization management team members
Leads and champions change within scope of responsibility
Performs other duties as assigned
Complies with all policies and standards
Qualification
Required
RN with Utilization Management experience (health plan, managed care, or hospital UM)
Experience with appeals and retrospective reviews
Active California nursing license
Graduate of an Accredited School Nursing or Bachelor's degree and 4+ years of related experience
RN - Registered Nurse - State Licensure and/or Compact State Licensure required
Preferred
Knowledge of utilization management principles
Benefits
Competitive pay
Health insurance
401K and stock purchase plans
Tuition reimbursement
Paid time off plus holidays
Flexible approach to work with remote, hybrid, field or office work schedules
Company
PA Health & Wellness
Established to deliver quality healthcare in the state of Pennsylvania through local, regional and community-based resources, PA Health & Wellness is a Managed Care Organization and subsidiary of Centene Corporation (Centene).
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
Justin Davis
President and Chief Executive Officer
Recent News
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