Manager, Utilization Management

Manages prospective and concurrent Utilization Management (UM) programs including prior authorization, concurrent inpatient and continued stay reviews including authorization and management of selected post inpatient care. This position reports to the Director of UM and coordinates with Case Management (CM) and Care Coordination (CC) Managers. The position is responsible for providing assistance with the development of UM desk procedures, training, auditing and implementing UM program policies consistent with contractual and performance management goals., * Provides leadership to ensure operational effectiveness and efficiency of prospective and concurrent UM including discharge planning activities to meet and exceed production and service-level goals.

• Provides coaching and oversight to staff to ensure staff success and development.
• Oversees the program quality assurance and quality improvement processes related to UM programs.
• Generates reports to identify trends and opportunities for process improvement.
• Facilitates efforts to enhance UM programs by working collaboratively with the UM Director and other Medical Management leaders to effectively manage contract and internal performance standards.
• Provides assistance with Desk Procedures (DP) development monitors and provides assistance with application use and training programs in support of DPs.
• Collaborates with Data Management staff for data compilation and statistical analysis regarding program outcomes.
• Develops audit reports to identify quality issues and to identify areas for enhanced staff training.
• Develops new training programs, training documents, and flow diagrams to address targeted operational issues.
• Collaborates with clinical leadership to implement new processes for enhancing service levels.
• Assists the UM Director with staffing projections for contract management and budgets.
• Performs other duties as assigned.
• Regular and reliable attendance is required.

• Registered Nurse with current, unrestricted license for appropriate state (RN)
• 5 years’ experience in a clinical setting
• 2 year experience with a managed care program
• 3 years supervisory or management leadership experience in a healthcare environment

Preferred:

• Commercial Managed Care experience
• Master’s Degree in Nursing or related field
• Veterans Healthcare or TRICARE Program experience
• Experience with policy development and technical writing
• Experience in budgeting, strategic program management and staff development, Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.

Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.

Delegation Skills: Provide clear performance expectations for projects and ensure adequate access to resources for completion.

Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources.

Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions.

Leadership: Successfully manage different styles of employees; provide clear direction and effective coaching.

Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment.

Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.

Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment.

Technical Skills: Thorough knowledge of health care delivery, clinical quality assurance program metrics, UM, CM,CC, managed care concepts, management reporting tools, and medical management systems; ability to perform critical, in-depth analysis of medical records for appropriateness and level-of-care determinations.

Working Conditions:

• Works non-regular hours, as required
• Works remotely, with 10% travel
• Extensive computer work with prolonged sitting
• Department of Defense security clearance required, We’re more than just a health care company. We’re passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes:
• Medical, Dental and Vision Coverage
• Paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time

TriWest job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $113,000 - $119,000 per year.

Taking Care of Our Nation’s Heroes.

It’s Who We Are. It’s What We Do.

Do you have a passion for serving those who served?

Join the TriWest Healthcare Alliance Team! We’re On a Mission to Serve®!

Our job is to make sure that America’s heroes get connected to health care in the community.

At TriWest Healthcare Alliance, we’ve proudly been on that important mission since 1996.