The UM Manager oversees the UM team is responsible for initial clinical review process. The department’s activities include serving as a resource for utilization management program and clinical guideline application assisting with clinical data collection, analysis and reporting, supporting UM Operations. Provides the team with clinical feedback and utilization training, tracking and monitoring turnaround times to assure service requirements are met, coordinating with operations and clinical team members to intervene when service levels are at risk, providing appropriate issue resolution and/or escalation when necessary, assuring timely letter generation and mailing, and coordinating the with Quality Department in preparation for internal and customer audits. The UM Manager collaborates with internal partners to ensure turnaround times are in compliance with customer, regulatory and accrediting agency standards, and CareCentrix standards and policies. Trains new team members and performs ongoing training of existing team. Monitors performance of team and individual members and takes appropriate action to ensure department goals are met. Works under general supervision.
• Candidate will possess excellent communication (verbal/written), organizational and interpersonal skills.
• Manage multiple tasks, be detail oriented, be responsive, and demonstrate independent thought and critical thinking.
• Effectively manages UM clinical activities including but not limited to data collection, analysis, reporting, tracking, monitoring turnaround times, assuring requirements are met, issue resolution, audit preparation.
• Implements and maintains standardized operations processes to ensure compliance with CareCentrix policies, customer requirements, legal requirements and regulatory mandates.
• Designs and implements strategies and best practices that drive process and performance improvements.
• Partners with Operations Leadership, Clinical Management, and the Quality Department to support clinical and utilization management goals and objectives.
• Audits cases to monitor and promote compliance with payer criteria and utilization guidelines, clinical operation policies and CareCentrix policies.
• Monitors performance and productivity of team and individual managers/supervisors. Takes appropriate action to ensure guidelines and goals of the department are met. Completes performance reviews. Mentors team members. Participates in development of individual associates.
• Defines and implements quantitative performance measures to establish performance objectives and continuously raise performance standards.
• Performs interviews as needed to ensure that a high-performing team is recruited and developed to achieve priorities.
• Ensures new hire orientations are conducted and assesses the effectiveness of orientation programs. Administers CareCentrix employee terminations, ensures the appropriate paperwork is processed, conducts exit interviews, and monitors/tracks reasons for termination.
• Conducts regular staff meetings to ensure the needs of patient/clients/families, providers, payers and referral sources are met.
• Attends/participates in staff development programs and obtains continuing education as required by company policy and licensing bodies. Interacts with referral sources to facilitate communications, answer questions and resolve problems.
• Participates in implementing / maintaining operational processes to promote compliance with Company policies, legal requirements and regulatory mandates.
• Participates in special projects and performs other duties as assigned.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Embraces the values of accountability, consistency, engagement, empowerment, respect and outstanding service. This position requires excellent organization, communication, and problem solving skills, as well as the ability to effectively interact with all levels of management and highly diverse customers. Must be extremely detail-oriented and understand the critical importance of accuracy and timeliness. Demonstrates critical thinking and has the ability to analyze data to understand an expected outcome. Must be able to effectively manage and prioritize tasks and thrive in a fast-paced environment.
• Abides by and demonstrates the company Mission – Vision – Values through both behavior and job performance on a day-to-day basis.
• Convey a strong professional image, exhibit interest and positive attitude toward all assigned work.
• Adheres to and participates in Company’s mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices.
• Reviews and adheres to all company policies, procedures, and the Employee Handbook.
• Must be able to remain in a stationary position 90% of the time.
• Occasionally move about the office to access file cabinets, office machinery, etc.
• Constantly operates a computer and other office productivity machinery (i.e., a calculator, copy machine, and computer printer).
• Frequently communicates via phone and email. Must be able to exchange accurate information in these situations.
• Occasionally lift items weighing up to 10 pounds.
Clear and active Registered Nurse/LPN/LVN (based on allowable state practice act) license in any state(s) or jurisdiction in the United States is required. Minimum of five years’ experience with thorough knowledge of healthcare delivery systems and managed care regulations, utilization management, case management, process improvement, and re-engineering processes, contract terms/stipulations, and government regulations also required. At least one year previous management and leadership experience required. Competent and experienced with Utilization Management and Regulatory and Accrediting agency standards.
CareCentrix maintains a drug-free workplace in accordance with Florida’s Drug Free Workplace Law.