Job Summary:
Reports directly to the Health Plan Administrator and responsible for utilization management activities and strategies relating to coordination, concurrent review, discharge planning, prior 
authorization, case management and retrospective reviews to ensure effective and efficient provision of quality and appropriate health care services to TakeCare members.

Responsible for providing evaluation and services delivery to ensure quality, timely and appropriate utilization of treatment & delivery systems to ensure conformance with organizational policies, coverage guidelines and compliance with government regulations. Supervises and monitors utilization activities in the department, tracks and evaluates staff performance related to utilization review, processing, approval, and denials.

Essential Duties and Responsibilities:

Utilization Management:
• Reviews and analyzes medical information and provides oversight in reviewing, evaluating and determining the medical necessity of service treatment request to ensure that treatments are consistent with patient’s diagnosis, treatment plans, coverage guidelines and policies.
• Determines appropriateness of services based on consistent application of decision support and effective delivery system and takes responsibility in communicating to providers and patients in a timely and effective manner.
• Reviews financial and utilization data and prepares a comparative analysis of actual and benchmark/goals. Develops and recommends initiatives, strategies and programs in developing
improvement action plans as appropriate.
• Performs telephonic and/or onsite review of concurrent patient services and retrospective quality of care issues, access and outcome studies i.e., HEDIS, NCQA.
• Maintains ongoing database/documentation to monitor all activities/treatment and outcome plans for patients. This should be in conformance with organizational policies and guidelines and compliant with government regulations.
• Develops and maintains quality assurance measures to ensure consistency in application of decisions on requests for health care services, utilizing evidenced-based guidelines and criteria and decision support systems.
• Develops and implements tracking and control procedures to ensure that services being provided to eligible members are within the scope of the benefit plan and contracted providers are being utilized.
• Oversees the coordination and concurrent review of patients to ensure services are provided at the appropriate level of care utilizing evidence-based guidelines and criteria in the review and decision process.
• Provides feedback to physicians, providers, facilities and members regarding coordination and authorization process and treatment plan.
• Provides oversight of Case Management Program to proactively identify and refer catastrophically and chronically ill patients to case management using established criteria.
• Assist in developing industry recognized benchmarks for program tracking of caseloads, cost savings,and utilization.
• Coordinates and manages relationship with third parties to ensure timely and cost-effective services are delivered and routed to the appropriate health care delivery systems.
• Collaborates and reviews on-going cases with reinsurance partners to manage risks and costs.
• Collaborates and reviews potential high dollar cases to ensure that appropriate treatments are provided at cost effective delivery systems.

Management:
• Evaluates and reviews staffing requirements and responsible for scheduling to ensure adequate department coverage.
• Evaluates staff performance and conducts reviews according to company guidelines and protocol.
• Supervise daily department activities to ensure completion of deliverables based on established benchmarks and goals.
• Monitors team performance and develops streamlined and efficient processes through workflow improvement and process re-engineering.
• Coordinates and liaison with the Health Plan Administrator, Medicare Director and/or Peer Reviewer to ensure utilization strategies and initiatives are developed and implemented to          support overall cost effectiveness and health care quality is achieved consistent with company’s goals and objectives.
• Monitors and trouble shoot moderate to complex department issues in collaboration with the Health Plan Administrator and/or Medical Director
• Organizes and implements a regular communication session with Medical Management Staff, and other health care team members, and provides a venue whereby issues and concerns are discussed in a timely and effective manner.
• Conducts departmental staff development and enrichment training as needed keeping individual goals aligned with department and organizational goals and objectives.

Education and Experience:
1. Graduate of Bachelor’s Degree in Nursing or other related field; License required.
2. Minimum of 3 years (supervisory) or 5 years (managerial) experience with impressive track record in performing routine to complex utilization management activities and strategies relating to coordination, concurrent review, discharge planning, prior authorization, case management and retrospective reviews to ensure effective and efficient provision of quality and appropriate health care services
3. Minimum of 3 years management experience.
4. Effective team player. With very good interpersonal relationship skills and can work and relate well with co-employees, patients and customers.
5. Must have behavioral sensitivity, maturity, diplomacy and tact to address complex situations and handling irate customers.
6. Outstanding oral and written communication skills.
7. Strong ethics and a high level of personal and professional integrity.
8.  Must have basic familiarity of federal and state laws and requirements relating to healthcare management.
9. Computer literate and very highly proficient in using MS office programs.