Utilization Management (UM) Lead
The current healthcare landscape is ever-changing, but the desire to provide patients with better, more affordable care is consistent. Healthcare providers are working to evolve and support population health management and today’s value models, but there is still uncertainty in the market. Providers need a proven, integrated approach that takes the best of today’s technology and matches it with deeply experienced professionals.
Innovista Health Solutions is an Illinois-based service organization with management services operations in Illinois and Texas. We are currently looking for a Utilization Management Lead in our Oak Brook, IL office. At Innovista, we believe that positive forward movement in today’s uncertain healthcare market stems from the combination of innovative programs and dedicated people. Join the Innovista team and lead the charge to a better, more efficient healthcare system.
In conjunction with the Director of Utilization Management, this position provides hands-on expertise to help implement company strategies and provide oversight of assigned IPA Utilization Management program. This individual provides expertise in Utilization Management while managing a small team of UM nurses to help ensure the right care, at the right time and at the right place, for “every patient, every day.” The UM Lead is responsible for preparing for and conducting monthly client UM Committee meetings. This individual will have a strong work ethic, excellent relational skills, is self-directed, and enjoys working in a fast-paced start-up environment.
DUTIES AND RESPONSIBILITIES:
- Provides direct clinical supervision for UM Nurses and is responsible for overseeing day to day Utilization Management procedures for an assigned market.
- Acts as a resource for the UM Nurses (first point of contact for clinical clarification/education/staffing).
- Assesses work queue distribution status; assigns and reassigns work to ensure timeliness and equitable distribution of work.
- Participates in data analysis of utilization metrics.
- Prepares, participates and presents summary utilization management reports to UM/QM Committee.
- Act as a liaison for providers for complaint resolution/clarification of processes.
- Consults with the Medical Director on all cases that do not meet clinical criteria.
- Establishes a working relationship with the Medical Director to support and uphold the established guidelines and NCQA standards
- Maintains accurate and timely documentation in the EHR and review cases using MCG and/or Interqual criteria.
- Fully understands policies, procedures and operations of the Utilization Management program.
- Ability to function as a Utilization Management Nurse, conducting preserve, concurrent, and retrospective utilization management reviews when needed.
- Adheres to accreditation, contractual and regulatory time frames in performing all utilization management review processes.
- Participates in preparation for NCQA Audits.
- Coordinates complicated medical cases and retrospective requests with Medical Directors.
- Identifies potential stop loss candidates to be monitored and reports to senior level manager.
- Identifies Members in need of Case Management services and refers to CM.
- Assist with interviews and evaluations, participating in performance evaluations of employees.
- Assists in development, coordination and implementation of orientation and in-services for the Utilization Management Nurses.
- This position includes rotation in telephonic after-hours, on-call duties
- Other duties as assigned.
- Registered Nurse (RN) with current full, active, and unrestricted Illinois license
- Prefer at least 5 years of clinical experience
- Knowledge/experience in Medicare, Medicaid or Commercial UM required
- Experience with Milliman Care Guidelines (MCG) or Interqual highly desirable
- Experience in a Health Plan, IPA, or MSO setting
- Effective inter-personal relationship building skills
- Self-motivated and able to work under pressure.
- Ability to effectively manage multiple shifting priorities.
- Ability to construct grammatically correct reports using standard medical terminology.
- Proficient computer skills with Microsoft Office products and ability to learn department and job specific Software Systems.
- Ability to work independently as well as within a team in a fast-paced environment.
- Must maintain a valid Driver’s License and vehicle
- Ability to travel at least 30% for client meetings within the State.
- Eligible for consideration of partial work from home status upon completion of probationary period as designated by the direct supervisor
Innovista is dedicated to hiring passionate individuals who embody our core values: integrity, determination, and teamwork. We recognize the importance of work-life integration and seek to provide our employees with competitive benefits, which include:
- Comprehensive health plan options, dental, and vision coverage subsidized by Innovista
- Opportunity to work from home, based on position and manager discretion
- Company-paid benefits, such as short- and long-term disability, employee life, and AD&D
- Discretionary bonus
- 401(k) with company match
- Opportunity for career advancement and growth
- Flex time options may be available
This job is posted on Indeed and no other sites. We do not post salary ranges. Salary ranges posted on other sites are not tied to our labor market specifications and are not relevant.