Utilization Management Team Lead, Oak Brook, IL RN, LPN, LCSW, or LCPC
In conjunction with the Director of UM, this position provides hands-on expertise to help implement company strategies and provide oversight of assigned IPA Utilization Management program.
DUTIES AND RESPONSIBILITIES:
· Acts as a resource for the UM Nurses (first point of contact for clinical clarification/education).
· Assesses work queue distribution status; assigns and reassigns work to ensure timeliness and equitable distribution of work.
· Travels to assigned hospitals to talk with Management at MCOs on a regular basis.
· Participates in data analysis of utilization metrics.
· Prepares, participates and presents summary utilization management reports to UM/QM Committee.
· Act as a liaison for providers for complaint resolution/clarification of processes.
· Consults with the Medical Director on all cases that do not meet clinical criteria.
· Establishes a working relationship with the Medical Director to support and uphold the established guidelines and NCQA standards
· Maintains accurate and timely documentation in the EHR and review cases using approved criteria.
· Fully understands policies, procedures and operations of the Utilization Management program.
· Ability to function as a Utilization Management Nurse, conducting preservice, concurrent, and retrospective utilization management reviews when needed.
· Adheres to accreditation, contractual and regulatory timeframes in performing all utilization management review processes.
· Participates in preparation for NCQA Audits.
· Strong UM Experience
· Acceptable professional licenses: RN, LPN, LCSW, or LCPC in the state of IL
· At least 4-5 years of relevant professional experience, including medical management experience in health plans, provider, or MSO settings and quality chart reviews
· A minimum of three (3) years of responsible leadership experiences in management positions preferred
· Certified Case Manager (CCM) preferred.
· Knowledge/experience in Medicare/Medicaid and HEDIS criteria is highly desirable
If you or anyone you know is interested in this opportunity, please email us an updated copy of your resume for immediate consideration.