GENERAL SUMMARY
Responsible for the daily management in one or more of the various health services areas (Pre-authorization, Concurrent Review, Complex Case Management, Appeals, and/or Disease Case Management). Serves in an active managerial role to assist in the development, implementation, and evaluation of the utilization management process.
ESSENTIAL RESPONSIBILITIES
- Provides management and direction to one or more health services areas (Pre-authorization, Concurrent Review, Complex Case Management, Appeals, and/or Disease Case Management); including, staffing, training, monitoring, and evaluating.
- Reviews the timeliness, appropriateness, and medical necessity of the utilization processes performed by the staff. Prepare reports detailing the monitored activities.
- Actively participates in the development, implementation, and oversight of the department’s activities; serves in an adjunct role for policy and procedure development and implementation.
- Assists in the identification of issues which may adversely impact the attainment of department goals/initiatives (i.e., inpatient bed days per thousand, outpatient surgery utilization, etc.).
- Collaborates with other departments to educate providers, vendors, and members regarding network providers/specialists benefits and utilization management policies and procedures.
- Attends meetings with internal workgroups and external business parties.
- Assists in the identification and triage of potential quality improvement issues. Responsible for assuring issues are reported to the Quality Improvement Department.
- Responsible for compliance with State and Federal law regarding the handling of utilization management decisions and/or appeals. Ensures compliance with national accrediting body standards regarding utilization management decisions and/or grievances.
- Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including employment, termination, performance reviews, salary reviews, and disciplinary actions.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Registered nurse with active license in good standing in the state where job duties are performed.
- Bachelor’s degree or equivalent experience.
- Previous (5-7 years) experience in utilization management.
- Previous (3-5 years) clinical experience.
- Previous (3-5 years) managerial experience.
- Experience in program development preferred.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: First/Mid Level Officials and Managers
Primary Location: Tampa, FL, US
Organization: 10000 - Coventry Health Care - Corp
Schedule: Full-time
Job Posting: 2012-11-19 00:00:00.0
Job ID: 1212263