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Manager Anthem Utilization Review Jobs in Tennessee

Charlie Health

Utilization Review Specialist

Nashville, TN · Remote

$62K - $70K/yr

Participate in denial management, appeals, and peer-to-peer review processes Requirements * Active ... Knowledge of utilization review processes, medical necessity criteria, and healthcare regulations

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Manager of Utilization Review

ODYSSEY BEHAVIORAL GROUP

Franklin, TN • On-site, Remote

Full-time

Re-posted 16 days ago

Job description

Position Summary
The Manager of Utilization Review (UR) manages the daily operations of the UR practices for an assigned division. Leads This position ensures timely initial, concurrent, and retrospective reviews are conducted efficiently with a high degree of accuracy. The Manager of Utilization Review collaborates with leaders throughout the company to support denial prevention strategies, regulatory compliance and process optimization. This position serves as an internal subject matter expert and frontline people leader guiding and educating team members on UR functions, tracking and maintaining performance metrics, managing workflows and cross functional collaboration in support of organizational goals.
Relationships and Contacts
Within the organization: Maintains frequent and close working relationships with the Director of Utilization Review, Utilization Review Coordinators, Revenue Cycle team members, Admissions team members, Nursing leadership, milieu leadership, and all clinical team members.
Outside the organization: Initiates and maintains strong professional relationships with clients and families, insurance carrier contacts, referral partners and vendors, as needed.
Position Responsibilities
Essential Responsibilities
  1. Communicates professionally and effectively with multidisciplinary team members, insurance organizations and business offices, providing needed information in a logical, concise manner using technical language that accurately describes clients' condition(s) and treatment needs.
  2. Manages hiring and selection, onboarding training, regular coaching and supervision of Utilization Review Coordinators.
    1. Provides fair and consistent leadership and communication with team members.
    2. Promotes effective team dynamics within and between departments, facilitates team building and professional development for Utilization Review Coordinators.
  3. Assists team members with challenging cases, removing barriers and increasing access to care.
  4. Performs medical records reviews and ongoing training with clinical/medical team members within the assigned division.
  5. Performs regular audits of Utilization Review Coordinator's work to ensure quality and performance.
  6. Maintains current knowledge of Utilization Review process and trends, including denials and concurrent reviews.
  7. Revises processes in collaboration with the Director of Utilization Review to meet organizational goals, as needed.
  8. Utilizes effective documentation standards that support a strong historical record of actions taken on each account.
  9. Maintains a strict level of confidentiality for all client, company, departmental, and healthcare provider information.
  10. Escalates challenges and/or roadblocks to Director of Utilization Review for resolution, as needed.

Additional Responsibilities
  1. Maintains current knowledge of Utilization Review process, including denials and concurrent reviews.
  2. Functions within the guidelines of the corporate Code of Ethics and in accordance with Corporate Compliance standards.
  3. Reads, understands, adheres to, and models all company policy statements on ethics, conduct, and conflict of interests.
  4. Attends and completes all training within assigned time frames.
  5. Performs other duties as assigned.

Education and Experience
Position requires a bachelor's degree or equivalent in combined education and experience, and a minimum of three (3) years' experience with external review organizations or comparable entities doing pre-certification and concurrent reviews in mental health, substance abuse, and/or eating disorder facilities. Requires a comprehensive understanding of the admission, concurrent, continued stay, and retrospective reviews using established facility criteria.
Physical Requirements
  • While performing the duties of this job, the employee will be required to communicate with peers/public, clients and/or vendors.
  • Tolerant to various noise levels: noise level in the work environment varies - may be very quiet to moderate.
  • Job performance will require the ability to sit or remain stationary for extended periods of time.
  • While performing the duties of this job, the employee may be required to talk or hear, sit, and stand.

Additional Requirements
  • Clearance of pre-employment tests, and any other mandatory state/federal requirements.

Skill Competencies
  • Demonstrates a proficient knowledge of medical and behavioral health terminology, and techniques used to diagnose and treat various medical conditions; including practices, standards of care, symptoms, treatment alternatives, medications used for treatment, and preventative healthcare measures.
  • Demonstrated ability to successfully function under pressure in critical situations.
  • Demonstrated ability to effectively manage conflict and crisis situations.
  • Demonstrates strong problem solving and analytical skills.
  • Demonstrates the ability to consistently exercise sound judgment and a high level of discretion.
  • Demonstrates excellent organizational and time management skills.
  • Demonstrates a high level of collaborative skills working with a variety of groups.
  • Demonstrates excellent interpersonal and relationship building skills.
  • Demonstrates a high level of follow-through and attention to detail.
  • Demonstrates excellent verbal and written communication skills.
  • Consistently demonstrates and models alignment with company core values and mission.
  • Demonstrate proficiency with technology resources to include Microsoft Office programs.

Odyssey Behavioral Healthcare, LLC and its subsidiaries provide equal employment opportunities without regard to race, color, creed, ancestry, national origin, ethnicity, sex, gender, sexual orientation, marital status, religion, age, disability, gender identity, genetic information, service in the military, or any other characteristic protected under applicable federal, state, or local law. Equal employment opportunities apply to all terms and conditions of employment. Odyssey reserves the rights to modify, interpret, or apply this job description in any way the organization desires. This job description in no way implies that these are the only duties, including essential duties, to be performed by the employee occupying this position. Reasonable accommodations may be made to reasonably accommodate qualified individuals with disabilities. This job description is not an employment contract, implied or otherwise. The employment relationship remains "At-Will."

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