Virginia Premier Health Plan, Inc.

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AVP, Utilization Management

AVP, Utilization Management

Job Locations 
US-VA-Glen Allen
Job ID 
2017-4135

Job Description

Overview

This position is responsible for the leadership, direction, oversight and operations management for the organization's Utilization Management (UM) function. The Associate Vice President (AVP) interprets key performance metrics to develop plans, mobilize the work force, and achieve the organization's UM outcomes relative to improved experience of care.

 

This position builds and maintains strong collaborative partnerships with key partners in the Medical Management and other departments to include Care Management, Quality, Pharmacy, Appeals, Medical Directors, Claims and Provider Network Development. Also responsible for creating a strategic vision, processes tools, and procedures to assure ongoing visibility to operational performance of the department and company. 

 

 

Responsibilities

  • Develop, implement and monitor policies and procedures for Utilization Management (UM) pre-authorization, concurrent review, post service review (retrospective chart review), clinical practice guidelines, clinical protocols, and reporting quality of care issues identified during the UM process
  • Accountable for leadership and oversight of front line UM operational organization including UM Managers, UM RNs, UM LPNs, Pre-authorization Intake Managers and non-clinical intake coordinators
  • Oversee UM processes with regards to specialty programs to ensure compliance with Virginia Premier’s policy guidelines, standard operating procedures, external regulatory requirements and NCQA accreditation standards
  • Oversee and monitor the inter-rater reliability process to ensure that the UM team is meeting the established performance goal
  • Accountable for achieving established outcomes goals relative to UM operations
  • Innovate and implement new or revised models for the organization's UM operations functions in response to evolving trends in healthcare delivery and/or emerging models of care or in response to State and federal requirements
  • Provide clinical and operational oversight of each UM initiative which includes collaboration with analytics team and clinical trainers to review, understand and utilize the analysis of clinical data to drive performance improvement
  • Ensure ongoing review and revisions to the Utilization Management program descriptions annually or as indicated by contract or accreditation requirements
  • Drive cross-functional, cross-departmental communication and work processes that impact various departments of the company to improve clinical outcomes
  • Utilize industry standard and established benchmarks to monitor, track, and trend aggregated, product specific and plan specific UM metrics; communicate this information in monthly meetings with other clinical leaders, who are accountable for monitoring data and driving performance
  • Validate Utilization Management quality audit results for accuracy and individual developmental needs
  • Develop staff performance objectives based on identified improvement or developmental opportunities and aligns with organizational performance outcome objectives
  • Develop, implement, and monitor policies and procedures for contract and accreditation compliance
  • Participate in development of business requirements as needed to maintain and upgrade IT systems that support UM functions and interface with other critical IT systems including pharmacy, CM, and claims

Qualifications

MINIMUM EDUCATION REQUIRED

  • Minimum of five (5) years of clinical nursing experience is required
  • Current, unrestricted RN license in the Commonwealth of Virginia
  • Bachelor’s degree in healthcare related field, Masters preferred

SPECIAL KNOWLEDGE AND/OR SKILLS

  • Excellent verbal and written communication skills
  • Knowledge of NCQA and HEDIS
  • Strategic thinker
  • Results oriented leadership
  • Knowledge and experience with UM requirements for Medicaid, Medicare and Dual Eligible populations preferred
  • 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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