Commission Cvs Health Utilization Management Jobs in Wisconsin

Harris Health is the public healthcare safety-net provider established in 1966 to serve the residents of Harris County, Texas. As an essential healthcare system, Harris Health champions better health for the entire community, with a focus on low-income uninsured and underinsured patients, through acute and primary care, wellness, disease management and population health services. Ben Taub Hospital (Level 1 Trauma Center) and Lyndon B. Johnson Hospital (Level 3 Trauma Center) anchor Harris Health's robust network of 39 clinics, health centers, specialty locations and virtual (telemedicine) technology. Harris Health is among an elite list of health systems in the U.S. achieving Magnet® nursing excellence designation for its hospitals, the prestigious National Committee for Quality Assurance designation for its patient-centered clinics and health centers and its strong partnership with nationally recognized physician faculty, residents and researchers from Baylor College of Medicine; McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth); and The University of Texas MD Anderson Cancer Center.

At Harris Health, we prioritize the well-being of our most valuable asset--our people--ensuring a culture of compassion, collaboration and excellence in serving Harris County's most in need. With integrity and accountability at our core, we commit to 'leading with love', embodying our dedication to quality care, education, and a steadfast respect for every individual's contribution to our mission.

The Manager, Utilization Management (MUM) coordinates the design, development, implementation, and monitoring of the system utilization management functions with the aim to achieve clinical, financial, and utilization goals through effective management, communication and role modeling. This position is responsible and accountable for overseeing the coordination of services through an interdisciplinary process through the continuum of care and for also developing and leading strategic business initiatives and programs as assigned. The MUM must balance individually identified patient needs with cost effective utilization of resources, functioning as the internal resource on issues related to the appropriate utilization of resources, utilization review and management.

The role will lead process improvement projects to improve the delivery and measurement of integrated care within the organization. In conjunction with the Vice President, System Care Management and other Utilization Management leaders, this manager will plan, execute, and manage various initiatives related to UM administrative, operational, and strategic objectives. This role will manage day-to-day tasks, activities, and caseloads for UM Nurses and resources assigned to this program. The MUM also demonstrates leadership and effective communication by fostering collaborative relationships with peers, co-workers, and staff, working alongside Care Management as well as other interdisciplinary, cross-functional teams on a daily basis. This leader will assist in developing processes to create streamlined communication and relationships with all third-party payers for all UM Nurses as well as Care Management staff.

This position has the authority to make operational and human resource decisions relevant to his or her assigned area as long as decisions are consistent with Harris Health policies, standards, and other approved guidelines.

• Graduated from an accredited school of Nursing with a Bachelors in Nursing.
• Master's Degree in nursing, business, health administration, public health, social work, or healthcare-related field.

• Registered Nurse: Licensed to practice nursing in the State of Texas.
• Case Management Certification (ACM or CCM) within two years of hire.
• Basic Life Support: American Heart Association (AHA) or Red Cross approved program.

• 7 Years of Experience: Strong clinical background in a variety of acute healthcare settings including Case Management, Quality Management, or Coding as well as at least 3 years of Utilization Management experience.

• 2 Years of Experience: Supervisory or charge nurse role.

• Above Average Verbal Communication (Heavy Public Contact)
• Exceptional Verbal (Public Speaking)
• Writing/ Correspondence
• Writing/ Reports

• Bilingual Skills (Preferred)

• MS Word
• PC
• MS Excel
• MS PowerPoint

• Analytical
• Design
• Mathematics
• Medical Terms
• Other: Utilization review tools: MCG and or Change healthcare (Interqual)

• Flexible
• Weekends
• Telecommute
• Holidays

• Equipment Operated: Standard office equipment, computer software, etc.