Harrisburg, Pennsylvania
Director, Utilization Management (Experience Required) Job Opening in Harrisburg, Pennsylvania - Title: Director, Utilization Management
Location: Harrisburgh, PA
Job Type: Direct
Job description
Position Purpose:
Oversee operations of the referral management, telephonic utilization review, prior authorization functions, and case management programs.
Ensure compliance government and contractual guidelines and the mission, philosophy and objectives of Corporate and the health plan.
Oversee the operations of the referral management, telephonic utilization review, prior authorization, and case management functions.
Support and perform case management, disease management and on site concurrent review functions as support to Provider Relations issues related to Utilization issues for hospitals and physician providers.
Coordinate efforts with the Member Services and Connections Departments to address members and providers issues and concerns in compliance with medical management requirements.
Maintain compliance with National Committee for Quality Assurance (NCQA) standards for utilization management functions for the prior authorization unit.
Develop, implement and maintain policies and procedures regarding the prior authorization quality and risk management issues and facilitate the collection of information for quality improvement and reporting purposes.
Compile and review multiple reports for statistical and financial tracking purposes to identify utilization trends and assist in financial forecasting.
Qualifications:
:
Bachelor's degree in Nursing or equivalent experience.
5+ years of nursing experience in an acute care setting or medical/surgical, pediatrics, or obstetric in a managed care environment.
1+ years of utilization management and/or case management experience.
Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
:
Current state?s nursing license.
Experience in Medicaid and Medicare is highly preferred.
Strong computer skills are desirable.
Employee Status:
Regular
Job Level:
Director/Sr. Director
Job Type:
Regular
More information about the job
Is Relocation Available?
Yes, nationwide
Is there a bonus structure?
20% or higher
Are you open to sponsorship?
No
This position is:
New Position
Is there a possibility to work remote?
No
Is there equity?
No
Are there flexible work hours?
No
Does this position have direct reports?
Yes
Who does this position report to?
VP, Medical Management
What are the nice-to-have skills?
Experience coming from the health plan side.
What is exciting about this opportunity?
To be part of a growing, highly credible organization!
Job Type: Full-time
Required education:
Bachelor's
Required experience:
nursing in an acute care setting or medical/surgical, pediatrics, or obstetric in a managed care environment: 5 years
utilization management and/or case management: 1 year
Required license or certification:
Current state?s nursing license
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