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.