Description:
GENERAL SUMMARY
Responsible for the daily management in one or more of the various health services areas (Retro Review, Concurrent Review). Serves in an active managerial role to assist in the development, implementation, and evaluation of the utilization management process.
ESSENTIAL RESPONSIBILITIES
- Provides management and direction to one or more health services areas (Retro Review, Concurrent Review); including, staffing, training, monitoring, and evaluating.
- Reviews the timeliness, appropriateness, and medical necessity of the utilization processes performed by the staff. Prepare reports detailing the monitored activities.
- Actively participates in the development, implementation, and oversight of the department’s activities; serves in an adjunct role for policy and procedure development and implementation.
- Assists in the identification of issues which may adversely impact the attainment of department goals/initiatives (i.e., inpatient bed days per thousand, outpatient surgery utilization, etc.).
- Collaborates with other departments to educate providers, vendors, and members regarding network providers/specialists benefits and utilization management policies and procedures.
- Attends meetings with internal workgroups and external business parties.
- Assists in the identification and triage of potential quality improvement issues. Responsible for assuring issues are reported to the Quality Improvement Department.
- Responsible for compliance with State and Federal law regarding the handling of utilization management decisions and/or appeals. Ensures compliance with national accrediting body standards regarding utilization management decisions and/or grievances.
- Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including employment, termination, performance reviews, salary reviews, and disciplinary actions.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Registered nurse with active license in good standing in the state where job duties are performed.
- Bachelor’s degree or equivalent experience.
- Previous (5-7 years) experience in utilization management.
- Previous (3-5 years) clinical experience.
- Previous (3-5 years) managerial experience.
- Experience in program development preferred.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: First/Mid Level Officials and Managers
Primary Location: Louisville, KY, US
Other Locations: ,
Organization: 38500 - Coventry Health & Life-KY
Schedule: Full-time
Job Posting: 2013-05-21 00:00:00.0
Job ID: 1311824
GENERAL SUMMARY
Responsible for the daily management in one or more of the various health services areas (Retro Review, Concurrent Review). Serves in an active managerial role to assist in the development, implementation, and evaluation of the utilization management process.
ESSENTIAL RESPONSIBILITIES
- Provides management and direction to one or more health services areas (Retro Review, Concurrent Review); including, staffing, training, monitoring, and evaluating.
- Reviews the timeliness, appropriateness, and medical necessity of the utilization processes performed by the staff. Prepare reports detailing the monitored activities.
- Actively participates in the development, implementation, and oversight of the department’s activities; serves in an adjunct role for policy and procedure development and implementation.
- Assists in the identification of issues which may adversely impact the attainment of department goals/initiatives (i.e., inpatient bed days per thousand, outpatient surgery utilization, etc.).
- Collaborates with other departments to educate providers, vendors, and members regarding network providers/specialists benefits and utilization management policies and procedures.
- Attends meetings with internal workgroups and external business parties.
- Assists in the identification and triage of potential quality improvement issues. Responsible for assuring issues are reported to the Quality Improvement Department.
- Responsible for compliance with State and Federal law regarding the handling of utilization management decisions and/or appeals. Ensures compliance with national accrediting body standards regarding utilization management decisions and/or grievances.
- Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including employment, termination, performance reviews, salary reviews, and disciplinary actions.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Registered nurse with active license in good standing in the state where job duties are performed.
- Bachelor’s degree or equivalent experience.
- Previous (5-7 years) experience in utilization management.
- Previous (3-5 years) clinical experience.
- Previous (3-5 years) managerial experience.
- Experience in program development preferred.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: First/Mid Level Officials and Managers
Primary Location: Louisville, KY, US
Other Locations: ,
Organization: 38500 - Coventry Health & Life-KY
Schedule: Full-time
Job Posting: 2013-05-21 00:00:00.0
Job ID: 1311824