Manager, Utilization Management - Remote (Maine)

The Manager Utilization Review is responsible for oversight of utilization review operations including development and management of programs that emphasize appropriate admissions as well as prospective, concurrent, and retrospective review of care. Monitors team initiatives to meet departmental and organizational goals and objectives in support of the Health Plan’s successful achievement of the Triple Aim. The Manager will have a day-to-day awareness of each team’s case load, and performance ensuring consistency of decision making, quality of service, and cost containment.
As an active member of the Health Plan leadership team, the Manager will serve as a subject matter expert with specific focus on mentoring new team members, assisting with training and development, and providing guidance and support.

• Ensures that utilization review programs and guidelines are aligned with current industry evidence-based practice, as well as local, national, and regulatory compliance standards
• Manages the utilization review operations of the Health Management Department including the referral and authorization process, benefit and medical necessity review, clinical auditing, concurrent review, and appeals.
• Regularly monitors program evaluation metrics and measurements to ensure that targeted Utilization Management interventions remain relevant and appropriate.
• Ensures turnaround time standards for all lines of business as well as the notification process (oral, written, and electronic).
• Participates in technology, system planning and enhancement; recommends and tracks technology modifications that support the utilization review processes.

• Assists the director with budget activities and helps to forecast FTE and other resource needs to ensure efficient UM operations.
• Serves as clinical department representative in Plan committees, focus groups and other strategic and operational interdepartmental initiatives.
• Collaborates with other department managers and team members to achieve departmental and organizational goals.
• Identifies opportunities for process improvement and initiates or delegates projects.
• Ensures compliance with and integrity of all departmental, organizational, and accrediting policies, processes, benefit guidelines and professional standards of practice with contractual, regulatory, and accreditation requirements.
• Works closely with the Director Health Management, medical director staff, and compliance and legal counsel on a variety of departmental functions and issues, as necessary.
• Assists with development of new administrative policies; annual review of all departmental policies in conjunction with HMD Leadership and MPHC Medical Directors.
• Assists in performing utilization reviews in a back-up clinical capacity.

• Bachelor’s degree in healthcare field required with BSN preferred, Master’s in nursing or related field preferred
• 5 years of utilization review experience in a managed care setting including experience in a leadership role.
• RN experience in a clinical setting required

• Current Licensure as an RN in Maine and other appropriate jurisdictions as necessary
• Certification in Managed Care Nursing preferred

• Demonstrates an understanding of and alignment with Martin’s Point Values
• Detailed knowledge of applicable regulatory and accrediting body standards (National Committee of Quality Assurance (NCQA), Centers of Medicare and Medicaid Services (CMS))
• Excellent interpersonal, verbal, and written communication skills
• Critical thinking: can identify root causes and implement creative solutions; analyze and apply data to inform decision-making
• Ability to demonstrate a clear understanding of the standards of professional practice in decisions, leadership, and documentation
• Ability to prioritize time and manage multiple competing demands efficiently and effectively for self and others
• Ability to function independently
• Computer proficiency in Microsoft Office products including Word, Excel, and Outlook