The Clinical Utilization Management Supervisor oversees the team that handles the denial review process for UM Operations. The Clinical Utilization Management Supervisor ensures that the denial, physician review process, and turnaround times are in compliance with customer, regulatory, accrediting agency standards as well as CareCentrix standards and policies. The Supervisor trains new team members and performs ongoing training of existing team.
• Effectively supervises UM Elevation activities including but not limited to clinical consultation, elevation of cases for physician review, data collection, analysis, reporting, tracking, monitoring turnaround times, assuring requirements are met, issue resolution, timely letter generation and mailing and 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.
• 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.
• 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.
CareCentrix maintains a drug-free workplace in accordance with Florida's Drug Free Workplace Law.