Manager, Clinical, Utilization Management

Manager, Clinical, Utilization Management
Manager, Clinical, Utilization Management
Who are we?
Versant Health is one of the nation's leading administrators of managed vision care, serving millions of our clients' members nationwide. We are driven by our mission to help members enjoy the wonders of sight through healthy eyes and vision.
As a Versant Health associate, you can enjoy a comprehensive Total Rewards package, which includes health and dental insurance, tuition reimbursement, 401(k) with company match, pet insurance, no-cost-to-you vision insurance for you and your qualified dependents. We are also invested in your success. There are many opportunities for advancement and development throughout all stages of your career with us.
See how youcan make a difference with the support of strong leadership and a team environment.
See Everything, Be Anything™.
What are we looking for?
The Manager of Utilization Management Operations will be responsible to oversee Utilization Management staff charged with promoting quality member outcomes, optimizing member benefits, and promoting effective/efficient use of resources. Activities of the department include prior authorization review, and review and appeal support. The incumbent will work in conjunction with Claims Operations, Network Development & Operations, Information Technology, Compliance, Reporting, and Finance to support and continue to improve service delivery and quality.
Where you will have an impact

• Ensures adherence to departmental policy, medical policy, and member benefits in providing services that are medically appropriate, high quality, and cost effective
• Ensures that Utilization Management cases are completed within the require timeliness requirements for Medicare, Medicaid, and Commercial lines of business
• Areas managed may include authorizing vision related outpatient services (surgical and diagnostic procedures) by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products
• Works daily with clinical staff performing UM reviews to ensure case and ensure proper checks and balances are in place between administrative and clinical staff
• Supports member and provider appeals process as required
• Hires, trains, coaches, counsels, and evaluates performance of direct reports. Responsible for management of Quality Review Nurse (s) and 10 - 15 Utilization Management representatives
• Analyzes essential facts, makes timely and sound decisions, makes recommendations, and resolves performance and job-related issues
• Develops and provides training and education to direct reports to support client requirements and regulatory standards governing the applicable line of business. Writes standard operating procedures to support staff education.
• Partners with other members of the Utilization Management Leadership team to support operations and business requirements to meet changing business needs and improve efficiency and service.
• Knowledge of NCQA Utilization Management requirements. Applies UM standards to daily work. Provides support to NCQA reaccreditation processes.
• Completes UM policy monthly / annual reviews. Completes applicable research to update polices. Collaborates with Compliance Department as needed.
• Supports companywide strategic initiatives
• Handles all incoming Utilization Management requests in accordance with all statutory, regulatory, accreditation and contractual requirements
• Participates in client audit administrative processes to ensure that all client contractual performance guarantees are met
• Requires rotation to weekends to provide managerial oversight to staff working on the weekend

What's necessary to do the job?

• Graduate from an accredited nursing program
• Current unrestricted RN license - the state of Maryland preferred
• Bachelor's Degree in Nursing, preferred
• Requires minimum of 5 years of clinical experience
• Minimum of two years of managed care experience with a healthcare payer organization
• Requires minimum of 1 year supervisory or management experience in a health plan or healthcare related field and preferably in Utilization Management
• Proven experience with government programs such as Medicare and Medicaid

HIPAA & Security Requirements
All Associates must comply with the Health Insurance Portability Accountability Act of 1996 (HIPAA) as it pertains to disclosures of protected health information (PHI) as described in the Notice of Privacy Practices and HIPAA Privacy Policies and Procedures. As a component of job roles and responsibilities, Associates may have access to covered information, cardholder data or other confidential customer information which must be protected at all times. As a result, Associates must explicitly adhere to all data security guidelines established within the Company's Privacy & Security Training Program.
Versant Health will never request money from candidates who seek employment with us and will never ask for any payment as part of the recruitment process.
Versant Health is a proud Equal Employment Opportunity and Affirmative Action employer dedicated to attracting, retaining, and developing a diverse and inclusive workforce. All qualified applicants will receive consideration for employment at Versant Health without regards to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, age, disability, national origin, marital or domestic/civil partnership status, genetic information, citizenship status, uniformed service member or veteran status, or any other characteristic protected by law.
The wage range for applicants for this position is [$100,000.00 to $110,000.00].
All incentives and benefits are subject to the applicable plan terms.
Other details

• Job Family Manager/Supervisor
• Pay Type Salary
• Employment Indicator CareSource

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