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Nurse Manager
ID: 151306 - Save Job
Category: Call Center
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Responsibilities Responsible for staff management and operations in the Care Management Department (Utilization Management, Case Management, Pre-Authorization Call Center and Appeals Program). Direct and supervise staff in accordance with departmental, Fund policies and procedures, and CBA, as appropriate; monitor staffing levels, assign and delegate responsibilities to achieve departmental objectives. Analyze all processes on an ongoing basis to determine their effectiveness, eliminate inefficiencies and makes changes to improve workflow and operations. Author operational workflows, policies and procedures to capture process change and revise current polices and procedures as necessary for effective and efficient execution of UM activities. Author new clinical policies and annual update of existing policies to support the SPD for presentation at periodic medical policy committee meetings. Responsible for the pre-and post meeting activity. Ensure compliance with response times with UM determinations, appeals and call center performance. Intervene in complex cases that require management level review and evaluations. Ensure staff excellence through continuous evaluation of quality audit outcomes and inter rater reliability results and oversee ongoing education and training to improve performance. Analyze reports for Care Management outcome results and make recommendations, improve processes, workflow and to sustain proficient business operations and staff development. Responsible for the oversight of the Automated Authorization Module – interact with QNXT support team with system updates and collaborate with claims processing department. Other duties and projects as assigned. Qualifications Current NYS Registered Nurse (RN) License Bachelor’s degree in nursing, business or healthcare administration or equivalent experience; plus Minimum five (5) years advanced or specialized work experience in Care Management programs (Utilization Management/Case management/Appeals Programs) within a managed care organization to include (2) years practical experience supervising both exempt and non-exempt personnel. Experience working with Milliman/InterQual and Medicare/Medicaid coverage guidelines, claims processing, medical coding and interpreting provider contracts. Participation in clinical policy development activities and experience in completing medical case reviews. Experience in Behavioral Health case management, Prescription Pre-Authorization, and Call Center operations a plus Strong critical thinking and analytical skills; effective troubleshooting and problem-solving abilities. Intermediate level of Microsoft Office Suite. Effective verbal and written communication skills; excellent time management and project management skills. Demonstrated management and team building skills, leadership qualities, and effective transition management skills. Commitment to building efficient care management programs which requires autonomy along with being an energetic team player and high performer; must strive in fast paced environment. Experience in a Union environment preferred.
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1199SEIU
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