POSITION DESCRIPTION Position Title: Manager of Utilization and Care Management FLSA Status: Exempt Department: Member Health Services Reports To: Director of Member Health Services Position Summary The Manager of Member Health Services leads our medical management team toward making a positive difference in our member’s lives by ensuring they receive the right care at the right time to improve clinical outcomes and lower costs. The Manager participates in identifying program improvements using evidence-based data to influence needed changes and developing department objectives, goals, and staffing assignments. The incumbent monitors and evaluates utilization review and care management determinations, documentation, and member and provider communications for efficiency, quality, accuracy, and adherence to best practice standards, such as Milliman Care Guidelines (Milliman) or National Committee for Quality Assurance (NCQA), as well as department processes and procedures, and ensures achievement of utilization targets. Objectives 45% TO OPTIMIZE UTILIZATION RESULTS AND ENSURE CUSTOMERS RECEIVE HIGH-QUALITY, COSTEFFECTIVE HEALTH CARE SERVICES as follows: Provide oversight of all aspects of case management including utilization review; hospital admission notification, inpatient concurrent review, denials management, patient advocacy, and transition of care processes and procedures. Interface with Quality, Provider Network Management, or other departments, external review agencies, or delegated vendors to ensure effective strategies in order to continuously improve the quality of care and services provided to members. Work collaboratively with others to continuously research, evaluate, and improve Utilization and Care Management Plans; staffing models; criteria, processes, desktop procedures; reports; and benchmarks that optimize utilization results and support enterprise and departmental business objectives and goals. Lead, initiate, or participate in department and corporate projects providing subject matter expertise on medical management and industry trends. Provide biannual cost-benefit analysis of the Trust’s Preauthorization List and make recommendations to the Director of Member Health Services and the Medical Advisory Committee. 55% Participate in recruitment, retention, and training and mentoring of medical management staff to meet performance goals. Oversee auditing of staffs work to ensure criteria and guidelines are adhered to, documentation is accurate and complete, and decisions are determined per policy; and evaluating staff educational needs and coordinating training. Monitor program performance, report risks to the Director of Member Health Services and provide remedial action plans. Ensure departmental targeted service levels and turnaround times are met. TO PROVIDE COMPETENT, EFFECTIVE SUPERVISION1 TO 11 EMPLOYEES WHO: Conduct thorough and objective evaluations of the members’ current physical, psychosocial, and environmental status; gathers relevant and comprehensive data specific to the targeted medical condition to validate intervention and risk level; and assesses resource utilization and cost management, diagnoses, past and present treatments, prognoses, and short- and long-term goals. Receive and accurately respond to both telephone and written requests for preauthorization from participants and providers in a courteous and prompt manner. Investigate and respond to participants’ questions and concerns regarding medical review determinations and claims payments. Coordinate the exchange of information between participants, consulting medical professionals, providers, and the WEA Trust (the Trust). Provide thorough and timely written notifications of medical review determinations. Qualifications Required for Appointment To be considered for this position, the applicant must demonstrate the following: Commitment to providing excellence in customer service and other Trust values. Ability to handle multiple time-sensitive tasks and prioritize in a fast paced environment. Experience auditing the accuracy of others’ work in a medical management setting and providing direction, training, and mentoring to staff. Management experience, including the ability to: o Assess individual performance and communicate assessments effectively. o Ability to identify and effectively and efficiently resolve employee performance problems or issues. o Ability to establish goals and assist others to achieve goals and meet expectations. o Ability to lead others to improve work processes. o Effectively manage change. o Build effective teams. Bachelors of Science in Nursing or other related field. Current unrestricted Wisconsin Registered Nurse license. Experience performing utilization review and case management in a clinical setting (hospital or home care preferred), including thorough knowledge of effective and efficient utilization review and care management best practices. Knowledge of and experience interpreting and applying managed care practices and the related regulations and standards, such as NCQA standards and accreditation, and InterQual/Milliman criteria and other guidelines for medical necessity, setting and level of care, and concurrent patient management. Familiarity with health insurance products, plans, regulations, and administration. Excellent written communication skills, including the ability to create clear, concise, and accurate training materials and correspondence and narrative reports for internal and external audiences. Excellent communications skills, including the ability to effectively and persuasively communicate with individuals; provide persuasive, credible educational presentation to groups; and to listen effectively. Excellent analytical skills, including the ability to identify problems, research and analyze issues from different perspectives, organize information, qualitatively and quantitatively measure program success, reach sound conclusions, and work cooperatively with others to develop and implement effective solutions. Experience utilizing MS Word, Excel, Outlook, and Access as well as experience with a medical claims transactional systems, and case management workflow software. Ability to work as an effective team member and to work collaboratively with staff at all levels at the Trust. Excellent organizational skills, including the ability to effectively and competently handle multiple priorities simultaneously and the flexibility and ability to quickly adapt to changes. Flexibility to work the number and schedule of hours needed to accomplish regular and ad hoc job responsibilities. Excellent performance in present and past positions. Preferred Qualification The following qualification is preferred for this position: Master’s degree in Nursing or related field. Qualifications Required for Successful Performance For successful performance, the incumbent must demonstrate the following: Excellent performance of all the foregoing duties assigned. Thorough understanding of the mission and the political context of the work of the Trust. Ability to improve effectiveness and efficiency within the domain of the incumbent’s assigned responsibilities. Commitment to continued learning in all areas relevant to the responsibilities of this position.