Top 43681 Utilization manager Jobs

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8d
Director of Case Management
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Emergency Department Manager
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10d

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Care Manager, Concurrent Review (Remote)

EmblemHealth -
New York, NY

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Job Details

$68,040 - $118,800 a year

Qualifications

RN License
Research

Full Job Description

Summary of Position

Perform clinical reviews within the Medical Management Operations Concurrent Review utilization management department.
Ensure accurate administration of benefits, execution of clinical policy and timely access to appropriate levels of care.

Principal Accountabilities

Under the direction of the leader, is responsible for the execution of efficient departmental processes designed to manage inpatient utilization within the benefit plan.
Act as the clinical coordinator collaborating with members and facilities to evaluate member needs within the inpatient setting.
Establish and maintain active working relationships with assigned facility care managers/utilization management departments to facilitate appropriate clinical reviews and patient care.
Enter and maintain documentation in the TPH platform meeting defined timeframes and performance standards.
Communicate authorization decisions and important benefit information to providers and members in accordance with applicable federal and state regulations, and NCQA and business standards.
Review and investigate member and provider requests to determine appropriate utilization of benefits and/or claim adjudication.
Research evidence-based guidelines, medical protocols, provider networks, and on-line resources in making coverage determinations and recommendations.
Prepare and present clinical case summaries in routine inpatient rounds.
Maintain an understanding of utilization management, program objectives and design, implementation, management, monitoring, and reporting.
Identify quality, cost and efficiency trends and provide solution recommendations to Supervisor/Manager.
Actively participate on assigned committees.
Perform other related projects and duties as assigned.

Qualifications

Education, Training, Licenses, Certifications

Associate’s degree or bachelor’s degree in nursing.
Valid RN License without restriction.
May require a CME accreditation in specific specialties.
Certification in utilization or care management preferred

Relevant Work Experience, Knowledge, Skills, and Abilities

4 – 6+ years of Nursing experience.
Case and/or utilization management/care coordination and managed care experience.
Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audience.
Organizing and prioritizing skills, and strong attention to detail.
Trained in the use of Motivational Interviewing techniques.
Experience working in physician practice and/or with electronic medical records.
Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.).
Proficiency with the use of mobile technology (Smartphone, wireless laptop, etc.).

Additional Information

Requisition ID: 1000002996
Hiring Range: $68,040-$118,800

Apply Now

Refine Your Search

utilization manager jobs

Care Manager, Concurrent Review (Remote)

Denials & Appeals Administrator (RN)

Utilization Review Specialist

Oncology Prior Authorization Case Manager, Non-RN - Remote

Operations Manager

Patient Care Manager 3D/3E/Burn

401(k) Specialist

Print Production & Business Consultant / Regional Field Support

Histology Manager

Rehab Supervisor (Physical Therapist) - Home Health

Manufacturing Engineering Manager

PACE Medical Director, Jordan Valley Senior Care

Area Service Manager

Team Medical Director

RN Case Manager Lead Wesley Long Hospital

Director of Clinical Services

Director of Case Management

Director, Pharmacy - Denver Health Medical Plan (* Hybrid Work Schedule *)

Clinical Director, AGL

Emergency Department Manager

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