Utilization Management Plan Oversight Manager

Location: Newark, DE

Primary Job Function: Medical Management

ID**: 34207

Job Brief

Qualified candidates must reside in Delaware. Current and unrestricted RN license in Delaware.

Your career starts now. We are looking for the next generation of health care leaders.

At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to connect with you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.

Responsibilities:

Reporting to the Chief Medical Officer for the Delaware Market, this position is representing UM in state interactions/audits, validation of regulatory reporting/analytics for UM DE, and serves as SME for clinical components DE Medicaid Utilization Management Program. Works in close collaboration with all departments to achieve regulatory standards and optimal departmental outcomes. Develops solutions that may consist of process improvements and/or system development components and are intended to optimize the functionality of the applications and related processes to support the business’ needs. Responsible for being final sign off for regulatory analytics validation. Analyzes the needs of the organization with the commitment to design and implement solutions that best support the needs of the business. This position will solicit ideas for systems improvements, review and present new system enhancements/features, and engage in continuous improvement planning, including testing and roll-out of configuration changes.

• Have working knowledge of prior authorization, medical necessity determinations, concurrent review, retrospective review, continuity of care, care coordination, and other clinical and medical management programs.

• Have working knowledge of all applicable statutory provisions, contracts and established policies and administrative procedures.

• Serve as designee for LOB Quality Meetings, corporate UM meetings, state UM meetings and functions.

• Assist in preparation, coordination, and participation in and follow up of Utilization Management audits, such as readiness review, Data Validation, CMS Program Audit and Compliance/Internal audits, pertaining to the DE Utilization Management program.

• Act as a primary liaison with plan providers including but not limited to physicians, hospital delegates, provider office personnel and health care vendors.

• Participate in coordination of internal and external Provider and Member directed communication regarding issues impacting DE Utilization Management coordination and delivery.

• Develop DE specific content for training to ensure that all new and existing staff are oriented to organizational and department policies and procedures. Track that credential of all licensed staff are verified in accordance with DE licensing agency initially and prior to expiration date. Maintain current and accurate files of such licensure and ongoing education status. Track that staff meets minimal skill and clinical knowledge requirements to be successful in assigned role.

• Assist in the development of mitigation or remediation processes from any deficiencies in scheduled Performances Reviews, CMS audits, DE EQRO audits. Establish action plan for assessment and resolution of identified issues.

• Participate in current process review and development of new and / or revised work processes, policies and procedures relating to DE Utilization Management responsibilities. Develop educational material and programs necessary to meet business objectives, members’ needs, DE contractual and regulatory guidelines and staff professional development.

• Chair of UM Committee. Examines peer reports, analyzes data, and utilizes reports to share information and educate within the provider network.

• Comply with Corporate, Federal, and State confidentiality standards to ensure the appropriate protection of member identifiable health information.

• Other duties as assigned.

Education/Experience:

• Qualified candidates must reside in Delaware.

• Bachelor’s Degree.

• Current and unrestricted RN license in Delaware.

• 3+ years utilization / case management experience in relevant scope preferred, one year required.

• 3+years relevant clinical practice required

• 3+ years of utilization management experience

• Demonstrated ability to assess department’s work quality and develop/implement process improvements to achieve contractual and oversight compliance.

• Experience in managing multiple processes and being and influencer.

• Demonstrated ability to analyze data and prepare data sets with trends to tell a story to stakeholders and leaders.

• Maintain a current knowledge of company policy and procedures Medicaid Medical Necessity guidelines and InterQual criteria access and delivery of services.

• Maintain understanding of managed care and impact on services including but not limited to, prior authorization, inpatient review, discharge planning, home health, and SNF/Rehabilitation Services.

• Strong organizational and prioritization skills.

• Excellent analytical and problem-solving skills.

• Exemplary communication skills in order to cultivate and maintain relationships with vendors, providers, VVMA, and external stakeholders.

• Strong computer skills. Proficiency, accuracy, and advanced working knowledge of all Microsoft applications to include Visio, Office, and SharePoint.

• Understanding of and expertise in quality and process improvement.

• Excellent/professional communication skills.

Diversity, Equity, and Inclusion

At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

EOE Minorities/Females/Protected Veterans/Disabled