Weekend Utilization Review Jobs in Madison, WI (NOW HIRING)

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for.

We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration — because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued.

This position is accountable for the day to day operational support and strategic activities of the assigned team. This position is also accountable for achieving department objectives and maintaining flexibility to meet business needs. Responsibilities include supervision of the clinical staff , ensuring that the strategic and business processes are established, maintained and communicated, and effective interdepartmental communications are established. This position resides in the Health Services  department, yet interacts regularly with other areas within Medica.

In addition to the coaching and staff development responsibilities, the Utilization  Management Supervisor must also build strong relationships with internal and external partners.  More specifically, support the Manager, Utilization  Management in relationship building within Medica and its vendor partners to help prioritize, integrate and coordinate interventions for population segments based on medical, behavioral and social needs.

This role oversees utilization  management projects, initiates and participates in quality improvement activities, and performs data monitoring of utilization activity for reporting to internal customers. The Utilization Management Supervisor will possess a strong working knowledge of Medicare and Medicaid regulations, mandates, and compliance standards.

The supervisor will support the manager and work with staff to integrate and understand accreditation requirements, and incorporate them into department  activities. The supervisor will conduct job functions in a manner, which consistently promotes a high level of customer service to both internal and external customers, models and supports the company’s core values and basic principles. This includes but is not limited to maintaining constructive and professional relationships with peers, supervisory personnel and internal and external customers, navigating internally and externally, facilitating change and serving as a role model, and proactively meeting customer’s needs in a timely fashion. Performs other duties as assigned. 

Key Accountabilities

• Supervise and Maintain Efficient Department Operational Systems/Process
  
  • Comply with policy and procedures effectively and with appropriate documentation and ensure team meets all department, regulatory and accreditation requirements and goals.
  • Informs the Manager of process, procedure, policy and other issues that cannot be resolved within the team
  • Model change management philosophies and support and facilitate a positive approach to change among team members
  • Monitor team members’ calls and casework to ensure staff is following department guidelines, processes and turn-around times.
  • Manage performance and hold staff accountable for meeting department standards for quality, turn around times, policy application, effectiveness, attendance, and personnel management, etc. Formulate action plan for less than acceptable performance
  • Consult human resources and manager to ensure compliance with company policies and values
  • Responsible for personnel management including interview process, goals establishment, performance review, and team-building
  • Assist with delivery of new employee orientation programs for team members, and contributes to the development, maintenance and communication of educational programs as indicated
  • Compile and report team and individual statistics for planning and evaluation
  • Assist the Manager to define and utilize performance standard to monitor staff performance
  • Accountable for driving performance toward goals and communicating effectively to peers when process gaps are impeding goals
  • Develops new and oversee the monitoring and updating of department SOPs (standard operating procedures).  Collaborates with team and communicates as needed
• Supervise Performance of Utilization Management Team
  
  • Leads and supervises the program and team as outlined under the Position Overview section
  • Assess the training and development needs of each new employee to result in fully competent performance within one year.  Assess existing employees for training and development needs or performance improvement plans
  • Provide team members with ongoing and consistent feedback, directed toward clinical excellence and accountability to department goals
  • Regularly assess and measure team workload and staffing ratios, ensure workload is evenly distributed. Develop and implement plan for backlog situations when needed. Communicate workload and turn-around times
  • Coach, encourage and facilitate individual growth and development through specific, timely and consistent feedback.  Conduct regular and timely one on one meeting
  • Ensure timeliness and accuracy of all required administrative functions, i.e. timecards, performance evaluations, call recordings, expense reports, etc.,
  • Communicate management decisions in a positive manner to staff
  • Accessible during workday to facilitate problem solving and resolution of case review issues and complaints
  • Take phone calls, handle escalated issues and provide setting for clinical case consultations
    Provide technical and clinical support to staff by researching and responding to their questions
  • Coach staff on the Quality Audit results.  Recommendations from audits are evaluated and appropriate improvement measures are taken

• Project and Group Management and Industry Knowledge

  • Work closely with project management team on implementation of new and renewing clients and for new and ongoing company and department initiatives
  • Exhibit skills in organization, project management, time management and meeting facilitation
  • Assist in the development, implementation or maintenance of department programs, which reflect quality of service and care as delegated by the manager
  • Represent Utilization Management at interdepartmental meetings and committees

• Establish and Maintain Positive Relationships with Internal and External Customers
  
  • Assist in developing and maintaining strong, positive and open relationships with the employer groups and other internal and external stakeholders
  • Listen to and understand customer’s questions, concerns or problems.

Required Qualifications

• Bachelor's degree in nursing
• 5+ years of clinical experience beyond degree, with 2+ of those years being in Utilization Management
• 1+ years of leadership experience

Required Certifications/Licensure

• Registered Nurse (RN) with active Minnesota license required

Skills and Abilities

• Strong working knowledge of Medicare and Medicaid regulations, mandates, and compliance standards.
• Expertise in communicating with staff in different positions and all levels of management positions
• Excellent customer service skills and proven team building skills
• Excellent computer skills including Microsoft Word, Outlook, Power Point and Excel
• High degree of initiative and ability to work independently, and within a group
• Demonstrated effective project management skills, including use of project planning and tracking tools; development of achievable goals, objectives, and timelines; and innovative use of resources
• Ability to plan, organize and prioritize work effectively, including the flexibility to accommodate frequent changes
• Strong problem solving skills
• Knowledge of NCQA, Motivational Interviewing, Evidence Based Medicine and coaching
• Consultant skills to articulate business needs and translate to quality programs that result in targeted staff competencies
• Strong leadership skills

This position is an Office role, which requires an employee to work onsite, on average, 3 days per week. We are open to candidates located near one of the following office locations: Minnetonka, MN or Madison, WI.

The full salary grade for this position is $78,700 - $134,900. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $78,700 - $118,020. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica’s compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States.

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.