Virginia Premier Health Plan, Inc.

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Director, Utilization Management (RN)

Director, Utilization Management (RN)

Job Locations 
US-VA-Glen Allen
Job ID 
2017-3749

Job Description

Overview

This position is responsible for providing oversight to the daily functions of the utilization management staff and monitoring staff performance in accordance with the VPHP policies and procedures.  Additional responsibilities include coordinating, conducting and documenting simple to complex Health Servies projects and operational procedures and identification of process. Also responsible for creating a strategic vision, processes tools, and procedures to assure ongoing visibility to operational performance of the department and company. 

Medical Management educates members and empowers them to become active participants in their coordinated health care plans. This team of knowledgeable professionals in their field provide services to include Utilization Review, Medical Outreach, Case Management, Disease Management, Credentialing, Social Work as well as Grievance and Appeals.

Responsibilities

  • Provides clinical and operational oversight of each Utilization Management initiative which includes utilization management and the analysis of clinical data to drive performance improvement.
  • Assist Directors of Care Management and Health Services with reviews and revisions to Utilization Management program descriptions annually or as indicated by contract or accreditation requirements.
  • Assist Directors of Care Management and Health Services with annual evaluations of Utilization Management programs per contract or regulatory requirements.
  • Identifies, assesses, develops, and implements cross-functional, cross-departmental work processes that impact various departments or the company to improve clinical outcomes.
  • Identifies opportunities to improve clinical care, customer service and internal business processes.
  • Collects, reports, trends, and analyzes Utilization Management program elements for departmental productivity and performance outcome reporting.
  • Provide expert assistance or best practice advice for team members.
  • Responsible for assessment, planning, implementation, tracking, monitoring, coordination, reconciliation and evaluation of the managed care members' performance across the continuum of care to include the complete transition of care to outpatient care.
  • Validates Utilization Management quality audit results for accuracy and individual developmental needs.
  • Develops staff performance objectives based on identified improvement or developmental opportunities and aligns with organizational performance outcome objectives.
  • Works closely with other managers and co-workers in order to ensure project deliverables are met in a timely and efficient manner.
  • Develops, implements, and monitors policies and procedures for contract and accreditation compliance.
  • Provides high level consultation to senior leaders for performance revisions integrations, and conversions, health-care strategies, product development, policy and procedure changes and/or cost control opportunities. 
  • Drives initiatives in the management team and organizationally that contribute to long term operational excellence.
  • Maintains strict confidentiality of member, provider company and personnel information.
  • Any other duties as assigned.

Qualifications

MINIMUM EDUCATION REQUIRED

  • Minimum of five (5) years of clinical nursing experience is required
  • Current, unrestricted RN license in the Commonwealth of Virginia
  • Bachelors of Science required, Masters preferred

SPECIAL KNOWLEDGE AND/OR SKILLS

  • Highly motivated individual with the ability to work independently as well as part of a team
  • Excellent verbal and written communication skills
  • Knowledge of NCQA and HEDIS
  • Demonstrated knowledge of Care Management principles
  • Strong analytical problem-solving, time management, and organizational skills
  • Proficient Microsoft Office product computer skills

 

WORK BACKGROUND/EXPERIENCE

  • Minimum of five (5) years of clinical nursing experience
  • Minimum of five (5) years of management experience in a managed care environment
  • Knowledge of medical terminology

PHYSICAL REQUIREMENTS

  • Physical health sufficient to meet the ergonomic standards and demands of the position.

ABOUT US

 

Virginia Premier Health Plan, Inc. is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 

 

We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  

 

All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

 

Our mission is to inspire healthy living within the communities we serve!

 

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