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Utilization Management Team Lead RN, LPN, LCSW, or LCPC

Managed Care Staffers Oak Brook, IL
  • Expired: over a month ago. Applications are no longer accepted.

Utilization Management Team Lead, Oak Brook, IL RN, LPN, LCSW, or LCPC

JOB SUMMARY:

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.

QUALIFICATIONS:

· 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.

Managed Care Staffers

Why Work Here?

Great opportunity!

We are employment specialists who have worked in heath care and managed care industry for over a total of 25 years. We staff temp, temp to hire, and direct hire placements

Address

Oak Brook, IL
60523 USA