Supervisor - Utilization Management Physical Health (Hybrid/Primarily Remote, North Carolina Based) at Alliance Health in Morrisville, North Carolina

Job Description:

The Supervisor – Utilization Management Physical Health, provides direct oversight of all aspects of Utilization Management as it relates to the management of physical health authorizations, workflows, and processes as well as all aspects of quality improvement activities. This position provides training and coaching for groups individuals, noting achievements and progress when completing individual performance evaluations as well as addressing and/or taking disciplinary actions if necessary. This position requires sound knowledge of clinical practice and exceptional leadership abilities. The UM Supervisor - PH may represent the unit in cross agency collaborative needs.

This position will allow the successful candidate to work a flexible and primarily remote schedule.  This is a remote position with some onsite if requested by the department or company.

Responsibilities and Duties

Implement unit goals and objectives

• Integrate the department and its functions into the organization’s primary mission


• Ensure the Utilization Management Department serves as an integrated department through effectively collaborating with Behavioral Health counterparts

Supervisor and develop Staff

• Work with Human Resources and Unit Director to maintain and retain a highly qualified and well-trained workforce


• Ensure staff are well trained in and comply with all organization and department policies, procedures, business processes and workflows


• Ensure the department has the needed tools and resources to achieve organizational goals and to support employees and ensure compliance with licensure, regulatory, and accreditation requirements


• Actively establish and promote a positive, diverse, and inclusive working environment that builds trust


• Ensure all staff are treated with respect and dignity


• Ensure standards are transparent and applied consistently, impartially, and ethically over time and across all staff members


• Work to resolve conflicts and disputes, ensuring that all participants are given a voice


• Set goals for performance and deadlines in line with organization goals and vision


• Effectively communicate feedback and provide ongoing coaching and mentoring to staff and support a learning environment to advance team skills and professional development


• Cultivate and encourage efforts to expand cross-team collaboration and partnership

Daily operational oversight of the UM Department reviewing physical health services

• Ensure consistent application of medical necessity criteria for physical health services that promotes a holistic review of the member’s needs


• Ensure compliance with performance measures outlined within NC DHB, NC DMH contracts and all accrediting body standards


• Monitor systems that ensure the authorization of services provided by clinical care staff appropriately address the service needs, types of service, outcomes, and alternatives available to consumers


• Provide education to hospitals, nursing homes and other care providers concerning departmental procedures and requirements for approving length of stay extensions


• Perform other related duties as required by the immediate supervisor or other designated Alliance Health administrators


• Analyze and monitor community capacity for service needs, service gaps, and the implementation of evidence based/best practices. 


• Review and Revise department Desk Manual as needed


• Complete mediations for denial or reduction of Physical Health Medicaid services completed by Alliance Health


• Represent Utilization Management determinations for Physical Health services in court as requested by legal counsel


• Assess and improve the department’s performance based on established indicators and outcomes


• Attend federal, state and local meetings as agency liaison


• Ensure authorized services address appropriate service needs, intensity of service outcomes, and alternatives for consumers


• Support Sr. UM Director and  UM Directors in reporting data and quality metrics

Inter-Departmental collaboration

• Maintain accessible and close working relationships with all applicable department heads and decision makers to develop a more coordinated and streamlined service delivery system for individuals and families throughout the service area


• Identify opportunities for  collaboration on inter-departmental projects that reduces duplication and ineffeciencies across the system


• Works with the Medical Directors with decision making of medical necessity cases, specialists, and primary care physicians


• Coordinate and integrate services within the department and with other departments


• Develop and maintain open timely communication with staff, providers, community agencies and other stakeholders

Minimum Requirements

Graduation from an accredited Nursing school and (5) years of experience in Utilization Management or substantially equivalent experience

Or

Bachelor’s degree from an accredited college or university in Nursing and three (3) years of experience in Utilization Management or substantially equivalent experience

 

Special Requirement-

Must have a current, active, unrestricted North Carolina license as a Registered Nurse.

 

Knowledge, Skills, and Abilities

• Must be knowledgeable in Utilization Management managed care principles and strategies


• Knowledge of physical health and co-morbid health conditions


• Knowledge of diagnostic treatment guidelines/protocols, level of care criteria


• Authorization/re-authorization Utilization Management standards


• Ability to develop and document workflows


• Written and oral communication skills


• Ability to analyze effectiveness of processes and make adjustments to developed processes


• Experience in acute clinical utilization review


• Experience in related duties in the delivery of patient care, management of patient care providers, or project management in a healthcare environment


• Demonstrates ability to interact with a wide variety of individuals, and handle complex and confidential sensitive situations


• Able to lead, delegate and problem solve


• Proficient in the use of computer and multiple software programs


• Ability to assist appeal efforts when medical care is denied by various payor entities in a timely fashion


• Experience with NCQA

 

Salary Range

$68,359.62 to $117,679.31

 

Education

Required

• Associates or better in Nursing

Licenses & Certifications

Required

• Registered Nurse

See job description

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