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RN Utilization Management Manager

Shawnee Mission, KS · Healthcare
RN Utilization Management Manager
Kansas City
Job# 11668434


Position Summary:
The Utilization Manager (UM) is responsible for Utilization Management activities, including but not limited to overseeing concurrent review and prior authorizations. The UM Manager develops, implements, supports, and promotes Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Aetna. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies. The UM Manager oversees and manages UM and Prior Authorization clinical team processes including the organization and development of high performing teams.

This position has the potential to require up to 25% in-state travel.

Additional Responsibilities of the UM Manager:
  • Ensures all UM staff have appropriate clinical licensure and experience in order to make UM decisions
  • Responsible for coordinating with the Behavioral Health and LTSS Medical Officers, Pharmacy Director and Behavioral Health Supports Director and other network staff to ensure delivery of holistic, integrated and person-centered care
  • Reinforces clinical philosophy, programs, policies and procedures
  • Communicates strategic plan and specific tactics to meet plan
  • Ensures implementation of tactics to meet strategic direction for cost and quality outcomes
  • Creates direction and communicates a business case for change by focusing on and addressing key priorities to achieve business results
  • Identifies opportunities to implement best practice approaches and introduce innovations to better improve outcomes
  • Accountable for meeting the financial, operational and quality objectives of the unit
  • May be accountable for the day-to-day management of teams for appropriate implementation and adherence with established practices, policies and procedures if there is not supervisor position
  • Works closely with functional area managers to ensure consistency in clinical interventions supporting our plan sponsors
  • Develop, initiate, monitor and communicate performance expectations
  • May act as a single point of contact for the customer and the Account Team which includes participation in customer meetings, implementation and oversight of customer cultural requirements, and support implementation of new customers
  • Participate in the recruitment and hiring process for staff using clearly defined requirements in terms of education, experience, technical and performance skills
  • Assesses developmental needs and collaborates with others to identify and implement action plans that support the development of high performing teams
  • Consistently demonstrates the ability to serve as a model change agent and lead change efforts
  • Accountable for maintaining compliance with policies and procedures and implements them at the employee level
  • Evaluate and interpret data, identify areas of improvement, and focuses on interventions to improve outcomes
  • Dedicated advocate for plan and members

    Required Skills:
  • 7+ years experience in clinical area of expertise
  • Experience in a Managed Care Organization (MCO) setting
  • Minimum of 1-3 years supervisory or management experience
  • Active unrestricted Kansas State Registered Nurse Licensure
  • Computer literacy and advanced proficiency with Microsoft Excel, Word, and web-based applications and Access databases
  • Reporting: ability to understand and create reports with productivity and service metrics; identify gaps; ability to evaluate and interpret data, to identify areas of improvement, and focus on interventions to improve outcomes
  • Demonstrated ability to deliver presentations to both internal and external customers
  • Knowledge of community resources and provider networks required; familiarity with local health care delivery systems
  • Experience working with diverse teams and populations
  • Strong communication and organizational skills with an attention to detail
  • Policy and procedure experience with a demonstrated ability to operationalize policies to desktops
  • Ability to work with people in such a manner as to build high morale and group commitment to goals and objectives

    Preferred Skills:
  • Minimum of 3-5 years in a MCO setting
  • Bachelor of Science in Nursing
  • Behavioral Health experience
  • IDD (Intellectual or Developmental Disability) experience

    Education:
    The minimum level of education required for candidates in this position is an Associate's degree or equivalent experience.

    Licenses:
    Active unrestricted Registered Nurse (RN) License for State of KS is required.
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National Recruiters LLC is an Equal Opportunity Employer
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