Manager Of Utilization Management (Remote U.s.)

CNSI and Kepro are now Acentra Health! Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact.

Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the company’s mission, actively engage in problem-solving, and take ownership of your work daily. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes – making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.

Acentra seeks a Manager of Utilization Management to join our growing team.

Job Summary:

Under the direction of the Director of Operations for the United Mine Workers Health and Retirement Funds (UMWA Funds) account, this position provides overall leadership for Utilization Management (UM) activities for a contract serving UMWA Funds beneficiaries. The Manager of Utilization Management oversees a department including, at a minimum, pre-certifications, concurrent reviews, durable medical equipment authorizations and coordination, travel authorization, prepayment claims review, and appeals.

Job Responsibilities:

• Oversee, coordinate, and monitor all Clinical team activities related to programs assigned.
• Ensure adequate staffing, contractual service levels, URAC requirements, and regulatory requirements are adhered to by implementing and monitoring clinical staff productivity and performance indicators.
• Maintains effective team member relations.
• Leads team members in improving skills, creativity, and problem solving.
• Work with management team and UMWA Funds Program Manager to develop and enhance the operational structure including skill set requirements, gap analysis, and training using workforce planning.
• Manages and completes assigned work plan objectives and projects on a timely basis.
• Provide advice and assistance to leaders in the planning, implementation, and evaluation of modifications to existing operations, systems, and procedures. Collaborate with leadership in the development of new and enhanced products and services.
• Represents the UM department by participating on committees, task forces, work groups, and multidisciplinary teams. Maintains professional relationships with provider community and external customers and identifies opportunities for improvement.
• Participates in the development and maintenance of policies and oversees clinical staff activities to ensure compliance with regulatory and accrediting standards.
• Provides reports of compliance and oversight and reporting of contract required Service Levels.
• Leads the auditing and development of team members.
• In collaboration with quality manager, develops and maintains quality improvement plans (QIPs).
• Leads management and maintenance of the Action Code Database and Universe Reports.
• Maintain a positive relationship with our client, by developing ongoing communication and collaborative approach to delivery expectations.

Requirements

Required Qualifications/Experience:

• Associates Degree or Bachelor's Degree in Nursing
• Active, non-restricted Tennessee (compact) Registered Professional Nurse license
• 5+ years of clinical experience required
• 3+ years staff/workload management experience
• Experience in Medicare
• Experience in Utilization Management

Preferred Qualifications/Experience:

• Expertise in one or more of the following areas: emergency medicine, medical/surgical, behavioral health, pediatrics, or cardiology.

• Demonstrated proficiency in MS Office applications.
• Experience in Utilization Management, claims, and appeals utilizing criteria such as Milliman, InterQual, ASAM, or similar.
• Experience with Medicare criteria for Utilization Management required.
• Ability to maintain a positive attitude and contribute both as an individual and a team member to achieve the goals of the department.
• Excellent medical record abstraction and quality management skills.
• Ability to professionally respond to change and handle multiple and changing priorities with sometimes conflicting deadlines.
• Knowledge and willingness to become a subject matter and thought leader for designated program(s).
• Knowledge of NCQA/URAC standards strongly preferred.

Why us?

We are a team of experienced and caring leaders, clinicians, pioneering technologists, and industry professionals who come together to redefine expectations for the healthcare industry. State and federal healthcare agencies, providers, and employers turn to us as their vital partner to ensure better healthcare and improve health outcomes.

We do this through our people.

You will have meaningful work that genuinely improves people's lives nationwide. Our company cares about our employees, giving you the tools and encouragement, you need to achieve the finest work of your career.

Benefits

Benefits are a key component of your rewards package. Our benefits are designed to provide additional protection, security, and support for your career and life away from work. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more.

Thank You!

We know your time is valuable, and we thank you for applying for this position. Due to the high volume of applicants, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Acentra Health and invite you to apply to future openings that may interest you. Best of luck in your search!

~ The Acentra Health Talent Acquisition Team

Visit us at Acentra.com/careers/

EOE AA M/F/Vet/Disability

Acentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by applicable Federal, State, or Local law.