Remote Aetna Utilization Review Jobs in Raleigh, NC

The Director of Utilization Management (UM) for Physical Health is responsible for administering and coordinating physical health utilization management activities for Alliance. This position ensures the UM Department operates as an integrated department providing a holistic review of member’s needs.  The position is responsible for overseeing a core component that ensures that individuals receive the correct level and intensity of services that results in positive outcomes.  This job also develops systems to monitor the appropriate utilization of both state and Medicaid funds.

This position is full-time remote. Selected candidate must reside in North Carolina and be willing to travel to the home office (Morrisville, NC) for onsite team meetings as needed.

Responsibilities & Duties

Develop and implement Unit goals and objectives

• Integrate the department and its functions into the organization’s primary mission.
• Ensure the Utilization Management Department serves as an integrated department through effectively collaborating with the Director of Behavioral Health Utilization Management and the Sr. Director of Utilization Management

Manage and Develop Staff

• Work with Human Resources and the Sr. Director of UM to maintain and retain a highly qualified and well-trained workforce.  
• Ensure staff are well trained in and comply with all organization and department policies, procedures, and business processes.
• Organize workflows and ensure staff understand their roles and responsibilities.
• Ensure the department has the needed tools and resources to achieve organizational goals and to support employees and ensure compliance with licensure, regulatory, and accreditation requirements.
• Actively establish and promote a positive, diverse, and inclusive working environment that builds trust.  
• Ensure all staff are treated with respect and dignity
• Ensure standards are transparent and applied consistently, impartially, and ethically over time and across all staff members.
• Work to resolve conflicts and disputes, ensuring that all participants are given a voice.
• Set goals for performance and deadlines in line with organization goals and vision.
• Effectively communicate feedback and provide ongoing coaching and mentoring to staff and support a learning environment to advance team skills and professional development.
• Cultivate and encourage efforts to expand cross-team collaboration and partnership.
• Effectively utilize and teach to the team how to effectively utilize authorization, claims and per diem data in order to remain within Alliance’s Cost of Care plan 
• Supervise UM Physical Health employees to assure accountability and productivity in meeting Department objectives and targets.

Oversee delegated UM vendors

• Oversee delegated vendors performing utilization reviews for physical health services. 
• Monitor UM vendors for compliance with delegation agreements and corrective action plans.
• Report analysis of non-compliance when identified.

Oversee the UM Unit reviewing physical health services

• Ensure consistent application of medical necessity criteria for physical health services.
• Participate in the development and implementation of department policies and procedures
• Ensure compliance with performance measures outlined within NC DHB, NC DMH contracts and all accrediting body standards.
• Protect client rights by ensuring all UM staff are trained and follow due process procedures, including the timely processing of treatment requests.
• Implement a system to maintain and assure that the authorization of services provided by clinical care staff appropriately address the service needs, types of service, outcomes, and alternatives available to consumers.
• Refine and evaluate the methods of authorization for services and treatment; develop strategies for accessing alternative to care.
• Provide education to hospitals, nursing homes and other care providers concerning departmental procedures and requirements for approving length of stay extensions.
• Analyze and monitor community capacity for service needs, service gaps, and the implementation of evidence based/best practices. 
• Advise on the  Alliance Medicaid and Non-Medicaid benefit plans that support the delivery and fidelity of evidence-based practices.
• Implement and montior systems to detect patterns of over and under utilization and implements corrective plans.
• Advise the Utilization Management Committee regarding service line trends and operational key performance measures.
• Perform other related duties as required by the immediate supervisor or other designated Alliance Health administration

Inter-Departmental Collaboration

• Maintain accessible and close working relationships with all applicable department heads and decision makers to develop a more coordinated and streamlined service delivery system for individuals and families throughout the service area.
• Identify opportunities for  collaboration on inter-departmental projects that reduces duplication and ineffenciencies across the system.
• Work with the Medical Directors with decision making of medical necessity cases, specialists, and primary care physicians

Minimum Education & Experience

Bachelors in Nursing with seven (7) years’ post-degree experience, including at least two (2) years of supervisory experience and two (2) years Utilization Management or substantially equivalent experience; 

OR 

Master’s degree in Nursing and five (5) years’ experience including at least two (2) years of supervisory experience and two (2) years Utilization Management experience or substantially equivalent experience.

Knowledge, Skills, & Abilities

• Must be knowledgeable in Utilization Management managed care principles and strategies
• Knowledge of physical health and co-morbid health conditions
• Knowledge of diagnostic treatment guidelines/protocols, level of care criteria
• Authorization/re-authorization Utilization Management standards
• Ability to analyze data and develop corresponding strategies
• Ability to develop and document workflows
• Written and oral communication skills
• Ability to analyze effectiveness of processes and make adjustments to developed processes.
• Experience in acute clinical utilization review
• Experience in related duties in the delivery of patient care, management of patient care providers, or project management in a healthcare environment
• Demonstrates ability to interact with a wide variety of individuals, and handle complex and confidential sensitive situations.
• Able to lead, delegate and problem solve
• Proficient in the use of computer and multiple software programs.
• Ability to assist appeal efforts when medical care is denied by various payor entities in a timely fashion.

Employment for this position is contingent upon a satisfactory background check, which will be performed after acceptance of an offer of employment and prior to the employee's start date. 

Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.