Utilization Management Jobs in Rochester, NY (NOW HIRING)

Job Description:

Summary:

This position serves as the expert and leader for clinical and care management activities and overall coordination of Case and Disease Management, specifically related to transplants and catastrophic conditions. This position oversees the clinical and administrative operations and implementation of Member Care Management activities, including systematic approaches to improve member health status, and expectation set forth by regulatory and accrediting entities.

Essential Accountabilities:

• Leads team members by communicating and guiding toward achieving department objectives. Establishes a foundation for strong teamwork and customer service. Provides ongoing supervisory and staff development and ensures adequate staffing to accomplish corporate goals. Participates in the recruitment, training and retention of staff.
• Provides planning and coordination of all facets of clinical care for potential and actual transplant candidates
• Manages end-to-end transplant activities, coordination, and education for members and families throughout the transplant process
• Manages catastrophic disease states/diagnosis such as cancer and transplants
• Maintains employee files with updated annual performance reviews, professional and mandatory education, and annual statements with signature.
• Instructs and acts as a resource for staff in dealing with special situations or problems.
• Conducts periodic case reviews, employee performance reviews, and staffing patterns, identifying areas needing improvement and initiates appropriate action including productivity monitoring and inter-rater reliability.
• Regularly monitors effectiveness measures such as productivity metrics, satisfaction survey results, and member complaints.
• Coordinates regular team meetings with staff.
• Ensures staff compliance with all regulatory and accrediting standards. Keeps abreast of changes and responsible for implementation and monitoring of requirements.
• Provides appropriate resources and assistance to staff with regards to managing cases per national professional standards, as well as other regulatory bodies. Provides updated information to training team and staff related to appropriate professional educational resources and serves as an information source for the department.
• Provides oversight for ongoing department specific staff training in collaboration with program supervisors and Care Management Training staff in support of new program development and/or initiatives
• Ensures operational processes are designed and implemented consistently and per department policies, procedures and guidelines. Facilitates quality, cost effective medical and benefits management and monitors results of the programs through outcome indicators.
• Provides presentations as they relate to specific functions of area supervised.
• Identifies strategies to improve healthcare resource management and communicates to internal and external customers.
• Represents department at quality oversight meetings when necessary.
• Facilitates interdepartmental coordination and communication to ensure delivery of consistent and quality health care services. Examples: Utilization Management, and Quality Management.
• Participates in the development or review of policies or standard operating procedures that support clinical and operational program operations.
• Maintains expert knowledge of current member program activities and serves as a resource for the implementation and training teams.
• Maintains documentation relative to the activities of the department and prepares reports as necessary, including those related to Quality Improvement Plan activities. Responsible for overall compliance and all regulatory and accrediting standards including NCQA formal accreditation activities. Keeps abreast of changes and responsible for implementation and monitoring of requirements.
• Performs ongoing program evaluation for effectiveness and value, and is responsible for providing ongoing input to department, division and corporate leadership as to the effectiveness of the MCM programs as well as identification of opportunity for enhancements to those programs for the benefit of our members and our company.
• Assists in implementing and monitoring departmental changes and initiatives necessary to accomplish corporate goals.
• Works in conjunction with leadership to respond to employer group requests for information and requests for proposals related to Member Care Management services.
• Works in conjunction with internal analytics and data teams to develop ongoing tracking systems, outcome driven data reporting, to obtain highly complex data and reports, as necessary.
• Leads and facilitates processes needed to analyze and improve processes and workflows on an ongoing basis.
• Keeps designated management aware of progress toward goals and productivity.
• Accepts responsibility for personal professional education requirements per departmental policy.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are compliant with these requirements.
• Conducts periodic staff meetings to include timely distribution and education related to departmental and Ethics/Compliance information.
• Performs other duties and functions as assigned by management.

Minimum Qualifications:

• Associates Degree required. Bachelors preferred.
• Must be a RN with current New York State license.
• Minimum of eight (8) years of relevant experience
• Minimum of four (4) years previous management experience, preferably in a health plan setting
• Must possess strong leadership skills, excellent written and verbal communication skills, project management and organizational skills, problem solving and analytical skills, ability to make decisions using solid judgment skills to impact identified problems, and the ability to work effectively with all levels of staff in the health care industry.
• Must possess knowledge of health insurance.
• Very strong working knowledge of corporate medical policies, InterQual and Milliman & Robertson guidelines, NCQA standards, HEDIS, CMS requirements, and NYSDOH medical management mandates & program requirements.
• Reads, analyzes, and understands complex statistical documents.
• Ensures accuracy of data. Demonstrates expert level ability of using statistical mathematics, research skills and calculations, and the use of software in the Member Care Management process.
• Ability to make presentations and interact professionally with internal management, employers, medical directors, members.
• The incumbent must be skilled in personal computer applications including Word, PowerPoint, and Excel.

Physical Requirements:

• Ability to work prolonged periods sitting at a workstation and working on a computer.
• Ability to work while sitting and/or standing while at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.
• Typical office environment including fluorescent lighting.
• Ability to work in a home office for continuous periods of time for business continuity.
• Manual dexterity including fine finger motion required.
• Repetitive motion required.
• Reaching, crouching, stooping, kneeling required.
• Ability to travel across the health plan service regions as needed.

************

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s):

E6: $79,068 - $142,32

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position's minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note: There may be opportunity for remote work within all jobs posted by the CDPHP Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.