Independent Health · 5 hours ago
Program Manager - Utilization Management
USA
Full-time
Remote
Mid, Senior Level
$85K/yr - $105K/yr
5+ years exp
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No H1B
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Responsibilities
Stay abreast of new clinical technology, treatments, testing and trends in the market to ensure medical and administrative policy is current and competitive within industry.
Optimize existing policy as it relates to medical management and utilization management by monitoring what services require medical necessity review, and making changes (add/remove) as needed.
Assess IH medical criteria vs MCG to define best practice use of criteria.
Evaluate and maintain annual evaluation of all medical necessity criteria.
Develop and maintain medical necessity criteria utilizing evidence-based literature and educate appropriate IH associates on the use and implementation of new criteria.
Monitor utilization trends and clinical appropriateness and make changes (add/remove) in services or suppliers as needed related to effectiveness of the Gold Card and Post Service Pre-Payment (PSPP) programs.
Develop and lead a cross-functional team (including Claims, IT, NCM, HCS, Servicing, and Product) to ensure consistent benefit interpretation across the organization.
Oversee and ensure accurate system configuration and appropriate benefit administration to demonstrate alignment between member contracts, regulatory requirements, provider reimbursement policies and medical policies.
Work collaboratively with multiple departments to continually assess and make recommendations for improvements to maintain an effective and efficient utilization management process and manage medical expenses based on trends.
Analyze utilization trends and costs and communicate recommendations and potential savings/impacts to HCS leadership.
Manage and support HCS team with regards to implementation and communication (internal and external) of new medical management processes.
Work collaboratively with training resources to ensure all medical management staff are updated on new product changes and impacts to functions.
Develop processes for the creation, tracking, and reporting of all benefit management changes within the medical management department.
Maintain UM review requirements and ensure implementation of any approved changes.
Maintain preventative list as designated by government entities.
Assist in medical management policy and SOP development.
Provide application systems expertise to client communities.
Participate in the Provider Communications team and others as designated as the HCS department representative.
Qualification
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Required
Bachelor’s degree required. Master’s degree preferred. An additional four (4) years of experience will be considered in lieu of degree.
Five (5) years of experience in health plan managed care operations required; multi-dimension project management experience preferred.
Knowledge of clinical care management processes, member benefit structures and applications, and claims processing.
Knowledge of medical necessity criteria development, claims systems, clinical platforms and/or CRM applications.
Prior experience with MCG and the MCG Modification tool functionality.
Ability to define problems, analyze data/information and critically think through scenarios.
Knowledge and experience in development of clinical processes and SOPs.
Knowledge of ICD-10, CPT and HCPCS coding.
Knowledge of program implementation with project management approach.
Excellent verbal, written and interpersonal communications skills required with emphasis on diplomacy, negotiation, persuasiveness and interaction with multiple levels of management.
Ability to work independently and lead or participate on multi-disciplinary project teams.
Excellent time management and organizational skills.
Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative and Accountable.
Preferred
Registered Nurse (RN) with active, unrestricted NYS license strongly preferred.
Certified Professional Coder (CPC) is strongly preferred.
Benefits
Scorecard incentive
Full range of benefits
Generous paid time off
Company
Independent Health
As one of Western New York's first HMOs, Independent Health covers approximately 355,000 people here and across the country with more than 100 plans, services and products.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Michael W. Cropp, M.D., M.B.A.
President and CEO
Jim Dunlop Jr.
Executive Vice President and Chief Financial Officer
Company data provided by crunchbase
