Manager, Utilization Management

Position Summary:
Commonwealth Care Alliance's (CCA) Utilization Management (Authorization) Unit is primarily responsible for the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of CCA's benefits plan.

The Manager, Utilization Management is responsible for overseeing and managing the daily operation of the Utilization Management Review Nurse and Specialist staff responsible for conducting centralized clinical review and authorization creation for centrally authorized services. This position has a key role in ensuring CCA meets CMS compliance standards in the area of service decisions and organizational determinations.

Essential Duties & Responsibilities:
The Manager, Utilization Management reports to the Director of Utilization Management

* Oversees clinical decision review for services requiring prior authorization in a variety of clinical areas, including but not limited to surgical procedures, Medicare Part B medications, long term services and supports (LTSS), and home health (HH).
* Maintains and optimizes Standard Operating Procedures related to authorization review
* Ensures timely and appropriate determinations of medical necessity, adhering to regulatory and contractual requirements.
* Maintain up-to-date knowledge of and compliance with CMS, NCQA and state Medicaid requirements.
* Lead preparation for internal and external audits (e.g. CMS Program Audits, or EQRO reviews).
* Hire, train and mentor UM staff, including nurse reviewers and support personnel.
* Act as liaison with medical director, provider relations, case management and quality teams to support care coordination and integrated care.
* Manages the process for escalated reviews in accordance with Standard Operating Procedures.
* Provides guidance to UM Nurses and clinical teams as needed
* Liaises with clinical teams and re-insurer on high-cost cases
* Ensures that department and organizational policies and procedures as well as regulatory and contractual requirements and other regulatory reporting needs are met.
* Tracks and monitors team's performance against targets; identifies, recommends, and implements opportunities for improvement as needed
* Investigates and resolves member complaints and grievances related to relevant services and supports; conducts audits and performs quality assurance
* Additional duties as requested.

Working Conditions:
* Standard office conditions.
* Office environment, some travel to clinical practices may be required.

Required Education (must have):
* Associate degree in Nursing

Desired Education (nice to have):
* Bachelor's Degree in Nursing

Required Experience (must have):
* 3-5 years utilization management experience
* 3+ years' experience working in a health plan, specifically with utilization management.
* Will be required to pass CCA's credentialing process

Desired Experience (nice to have):
* 3+ years management experience preferred

Required Knowledge, Skills & Abilities (must have):
* Expertise in managing utilization review processes including prior authorization, concurrent and retrospective reviews
* Demonstrated ability to establish and manage performance and outcome metrics.
* Excellent collaboration and communication skills with the ability to partner effectively across the organization and with external partners.
* In depth knowledge of medical necessity criteria (e.g. InterQual, CMS NCDS & LCDs) medical necessity guideline development.
* Ability to lead audit readiness efforts and ensure compliance with CMS, NCQA and state Medicaid regulations.
* Flexibility and understanding of individualized care plans
* Proficient in using data to drive decisions, identify trends, and recommend process improvements.
* Strong project management skills with the demonstrated ability to handle multiple projects.
* Ability to establish and maintain positive and effective work relationships with internal staff, external vendors, and state and federal agencies
* Proven skills and judgment necessary for independent decision-making.
* Excellent organizational, time-management and problem-solving skills
* Strong management skills
* Ability to influence decision making

Required Language (must have):
* English Required

Desired Knowledge, Skills, Abilities & Language (nice to have):
* Bilingual