Supervisor Utilization Management
Remote in ID, WA, UT, OR
The Supervisor Utilization Management supervises the team and acts as a resource for utilization management professional and support staff. Oversees and coordinates team activities to achieve business objectives and ensure medically necessary, cost-effective, quality care is delivered to members through various utilization management programs, including prior authorization and inpatient concurrent review, and regulatory compliance. May also be responsible for ensuring that medical payments are appropriate and in alignment with contract provisions, proper coding and policy compliance.
- Assigns and prioritizes work, sets goals, and coordinates daily activities of the team. Provides regular updates and communication to staff through 1:1 and team meetings.
- Monitors individual and team results to ensure work is completed in a timely manner, in accordance with department standards and procedures, and is in compliance with medical policy and medical necessity guidelines.
- Assists in development of productivity and quality standards. May conduct or participate in compliance audits and report audit findings. Identifies and implements process improvements as needed.
- Acts as a resource for staff and others. Appropriately escalates issues and partners with other departments to resolve issues and remove barriers. Collaborates with physician advisors on complex case and coverage determination processes.
- Participates in the hiring process, provides on-going coaching, employee development and writing of performance reviews. Develops and maintains desk reference guides on work procedures. Ensures new hires complete necessary training. Assesses training needs and plays an active role in development of staff.
- Completes special projects as assigned and may provide back-up support to staff as needed.
- Maintains clinical competency and keeps current on medical practices, procedures and industry trends.
- May develop and present educational updates to other departments.
- May develop and present educational updates internally or to other departments.
- Seeks ideas and opportunities for continuous improvement, determines which opportunities should be pursued and implements improvements as appropriate.
Normally to be proficient in the competencies listed above
- Demonstrated competency in setting priorities for a team and overseeing work outputs and timelines.
- Ability to communicate effectively, verbally and in writing including with members, employer or provider groups.
- Ability to effectively develop and lead a team (including employees who may be in multiple locations or work remotely).
- Demonstrated experience in recognizing problems and effectively resolving complex issues.
- Familiarity with health insurance industry trends and technology.
- Demonstrated competency related to clinical utilization management and care management practices.
- Ability to apply best practices and designated standards.
- Knowledge of payment coding guidelines, as applicable (Payment Review only).
A Supervisor of Utilization Management would have a bachelor's degree in Nursing or related field and 3 years of leadership experience and 5 years of clinical experience or equivalent combination of education and experience.Required Licenses, Certifications, Registration, Etc.
Must have license or certification, in a state or territory of the United States in the health or human services-related field that allows the professional to conduct an assessment as permitted within the scope of practice of the discipline (e.g. medical vs. behavioral health) and at least three years full time equivalent direct clinical care.
- For medical care management, must have a current unrestricted Registered Nurse (RN) license in a state or territory of the United States.
- For Behavioral Health Utilization Management, must have a current unrestricted state license in the profession (example: Social Worker (LCSW), in a state or territory of the United States
This position includes 401(k), healthcare, paid time off, paid holidays, and more. For more information, please visit www.cambiahealth.com/careers/total-rewards
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check are required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com