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Manager, Utilization Management

Manager, Utilization Management

Job Locations 
US-VA-Glen Allen
US-VA-Chesapeake
US-VA-Roanoke
US-VA-Bristol
US-VA-Charlottesville
US-VA-Winchester
US-VA-Alexandria
US-NC-Raleigh
Job ID 
2018-4539

Job Description

Overview

The Manager, Utilization Management is responsible for leadership and management of case and utilization management staff, including operational decisions, daily clinical decisions, process improvement, staff development, and compliance with Virginia Premier policies and procedures.

Responsibilities

  • Supervises Utilization Management (UM) and other support staff according to Virginia Premier policy and procedures to assure that UR reviews and activities are accurate, consistent, and performed in a timely manner.
  • Assists with the development of UM staff onboarding and training programs.
  • Coaches staff and supports healthy team dynamics.
  • Serves in an advisory capacity for problem solving, reviewing reports being sent to internal and external customers, reviewing problematic cases, and monitor utilization management activities.
  • Review specialized reports to identify trends and opportunities for improvement to enhance relationships with the provider network and service to members.
  • Ensure requirements for auditing UM decisions, documentation and quality are being met.
  • Assists Director of UM with ongoing Quality Improvement Program by assisting with various quality review tasks such as collecting and analyzing data as outlined in the program.
  • Assists in the ongoing development of programs and medical management projects to enhance/expand the medical management department.
  • Maintains confidentiality of patient information, and Virginia Premier proprietary operational information.
  • Maintains current knowledge of Virginia Premier policies and procedures.
  • Participates in continuing education activities as appropriate.
  • Participates in community programs (which may occur outside of normal business hours).
  • This position provides services and demonstrates the knowledge and ability to meet the specific needs of all age groups
  • Other duties as assigned.

Qualifications

REQUIREMENTS

  • Registered Nurse licensed to practice nursing in Virginia
  • Utilization Management experience
  • Management experience

SPECIAL KNOWLEDGE AND/OR SKILLS

  • Knowledge of evidence based criteria, such as Interqual.
  • Excellent problem solving skills
  • Patient assessment skills
  • Knowledge of community resources and vendor options, and experience in making appropriate referrals
  • Ability to negotiate with providers and vendors
  • Demonstrates excellent verbal and written communications
  • Demonstrates working knowledge of computers and word processing programs
  • Ability to build and support successful work teams
  • Possess knowledge of ICD-9 and CPT4 coding
  • Knowledge of Six Sigma Lean methodology or other Performance Improvement methodology

WORK BACKGROUND/EXPERIENCE

  • Minimum of 3 years utilization management experience, preferably in a managed care environment
  • Minimum of 1 year Management experience
  • Experience in clinical nursing
  • Experience working with low income disadvantaged populations.

PHYSICAL REQUIREMENTS

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

 

 

About Us

 

Virginia Premier 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.  

 

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

 

 

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