Manager Utilization Management - Medical Claims Review (Agriculture)

Responsible for the day-to-day operational management and supervision of the Utilization Management Review units, including: prior authorization, concurrent review, Medical Claims Review and Compliance for all Capital Blue Cross products. Retains ultimate responsibility for oversight of Quality Management for these programs. Responsible for administration of the program in accordance with NCQA, CMS, FEP and DOH standards and all regulatory bodies. Interfaces with multiple departments to facilitate smooth operations and promote the Program to group customers. Provides management and supervisory activities for authorizations and notifications, as well as effective management of activities that include work assignment, prioritization, and monitoring of results and taking actions to improve outcomes. Responsible for evaluation of cost containment strategies and quality management functions related to the delivery of these programs and services for all Capital Blue Cross products.

Duties and Responsibilities:

• Recruits, trains and manages a staff comprised of professional, technical and support positions. Delegates appropriate tasks to maximize use of individual skills and aptitudes. Reviews, counsels and motivates staff as appropriate.
• Meet no less than bi-weekly with direct reports and provide evaluation and feedback related to performance.
• Provide performance appraisals in a timely manner at a minimum of yearly. Coach and mentor staff throughout the year.
• Manages the daily operational activities. Responsible for effective management of performance within benchmark standards, using national guidelines to render determinations and services. Maintaining productivity and compliance.
• Focuses strategically on opportunities to improve operations based on industry best practices and market performance.
• Analyzes market/regional performance; identifies opportunities to improve, develop and monitor action plans.
• Monitors productivity statistics, reviews daily reports and trending and interfaces with external departments as needed.
• Maintains compliance for all reviews including monitoring of workflow queues to ensure timely reviews and notification. Reports on compliance standards and implements corrective action plans and process improvements if needed.
• Oversees the management of assignment within units. Monitors backlog situations and recommends solutions to operational problems within unit processes.
• Monitors inter-rater reliability in decision making, implements audit system for staff to maintain high level of quality performance, develops and implements improvement plans where inconsistencies are noted. Reports IRR results to appropriate Committee.
• Reports department performance to Director level and recommends improvement activities.
• Provides input into annual budget and provides monthly budget status reporting.
• Responsible to review and provide input into the development of unit specific policies and procedures and coordinate with corporate and departmental policies.
• Prepares reports as required for submission to appropriate internal department and regulatory bodies.
• Coordinates and oversees a clinical management-monitoring program through auditing.
• Implements programs that are compliant with state and federal regulations, and standards from accrediting bodies and other external regulatory entities.
• Chairs and conducts staff meetings at regular intervals to encourage collaboration between unit staff, offer and encourage continuing education and conduct quality improvement Initiatives.
• Participates in departmental planning sessions concerning programs and marketing activities.
• Assists sales staff and support personnel by participating in sales and informational meetings with customers. Interprets and explains unit policies and procedures.
• Works with other third party payers, Blue Cross/ Blue Shield Plans, and a variety of providers to coordinate and facilitate health care and financial arrangements necessary for utilization management activities.
• Works with the Medical Director to prepare agendas for and make presentations for various committee meetings, such as UMC.
• Fosters the development and maintenance of provider relationships and interfaces with facility representatives and network physicians.
• Assures that staff promotes high quality care through the appropriate utilization of health resources.
• Assures training of all staff on the process of effective utilization management and appeals and use of appropriate guidelines for all review determinations.
• Maintains operational interface with internal department including claims and customer service.
• Follows-up on legal inquires and employer group issues.
• Oversees that the practice of utilization management is conducted within the scope of staff licenses and/ or certifications.
• Meets and/or exceed identified unit KPI's.
• Collaborates with managers of other units to provide to increase productivity and communication.
• Demonstrates leadership by motivating teams to focus on initiatives, action and outcomes.
• Performs other related duties and assignments and directed.

Skills:

• Excellent verbal, public speaking and written communication skills.
• Strong managerial skills, including the ability to successfully interact with management and staff.

Knowledge:

• Knowledge of current and emerging medical treatment modalities, specifically for conditions medically classified as catastrophic or chronic in nature.
• Knowledge of population management programs, goals, strategies, outcomes and experience with the successful implementation of these programs.
• Knowledge of NCQA, CMS, state and federal regulations including DOH standards.
• Knowledge of Act 68 and ERISA requirements.
• Knowledge of all Capital and commercial carrier programs. Includes knowledge of clinical management policies/ procedures applicable to Capital's indemnity and PPO product lines.
• Knowledge of Blue Cross, Blue Shield, FEP and Medicare benefit coverage and limitations. Knowledge of the interrelationships of benefit coverage.
• General knowledge of Capital's provider payment practices and rates of payment. Ability to ascertain the reasonableness of providers' requested payment levels on individual cases.
• Knowledge of managed care offerings and how benefits are to be interpreted delivered and managed.
• Knowledge of providers, network functions and payment processes.
• Knowledge of how medical management processes and polices affect claims payment.
• In-depth knowledge of strategic and operational requirements necessary for the successful implementation of medical management.
• Knowledge of workload planning and staff management concepts to appropriately manage the day-to-day activities of the unit.
• Knowledge of central Pennsylvania medical environment and practice patterns.

Experience:

• Three to five years of experience in a managed care/health insurance medical management operation, as well as five years of clinical and three years of successful managerial experience.

Education and Certifications:

• Minimal requirements include a Registered Nurse or Licensed Practical Nurse with an active Pennsylvania license. A Bachelor's degree in a health or business related field is preferred.

Work Environment:

Sedentary work involving significant periods of sitting, talking, hearing, keying and performing repetitive motions. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor. Working environment includes typical office conditions.

Physical Demands:

While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must be able to work over 40 hours per week. The employee must occasionally lift and/or move up to 5 pounds.

Other:

• Travel
  • Must possess a valid driver's license.

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Capital BlueCross is an independent licensee of the BlueCross BlueShield Association. We are an equal opportunity/affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.