- Registered Nurse with a minimum of 5 years clinical experience.
- At least two years of experience should be in a management capacity.
- Minimum of a Bachelor of Science degree in Nursing or willingness to obtain within two years of hire.
- Holds active and unencumbered Ohio and West Virginia registered nurse license.
- Minimum of five years in a managed care organization.
- Public speaking and excellent written communication skills, motivation and initiative, and ability to work independently.
- Superior work ethic.
- Experience in writing policies and procedures.
- Proven leadership abilities.
- Strong verbal, written, analytical, and interpersonal skills.
- Flexible and able to multi-task, work in a fast-paced environment and adapt to changing processes.
- Self-starter with strong entrepreneurial skills.
- Certification in related area preferred, Certified Managed Care Nurse (CMCN).
- Oversees medical and behavioral UM and A/G operations.
- Provides direct supervision to the managers and supervisors.
- Develops and monitors utilization management and behavioral health staff UM and A/G training program.
- Participates on all clinical services and A/G committees.
- Development and continual review and revision of all UM and A/G processes, policies, and procedures within the department.
- Develops and enhances system of management reporting and metrics to be utilized for productivity, adherence, and outcome measurements to provide relevant information on overall effectiveness in UM and A/G areas.
- Ensure department optimizes UM and A/G workflow efficiencies to meet company objectives.
- Ensures that all medical and behavioral UM and A/G programs are delivered consistent with applicable internal policies and procedures as well as applicable CMS, BMS, NCQA or other regulatory agency requirements.
- Ensures UM and A/G medical/behavioral health program compliance to quality outcomes.
- e.g. STAR measures, HEDIS, CCIP, QIP and PIPs.
- Responsible for medical management/behavioral health annual risk assessment related to UM and A/G.
- Collaborates with the CMO, VP of Clinical Strategic Initiatives and Director of Clinical Programs on initiatives and interventions to ensure cross-functional and inter-departmental alignment with organizational goals.
- Leads medical management and behavioral health UM integration with provider health systems.
- Implements and monitors medical management, behavioral health, and third-party UM software programs.
- Provides input into clinical services medical/behavioral evidence-based UM criteria.
- Leads clinical services UM and A/G compliance and NCQA UM and A/G initiatives.
- Interacts with government agencies, health systems, and employer groups to facilitate medical and behavioral UM and A/G integration.
- Leads the BH and Medical transition of care teams and ensures workflow efficiency as well monitors the program for return on investment.
-
Director, Utilization Management
3 weeks ago
The Health Plan of West Virginia, Inc. Wheeling, United StatesThe Director of Utilization Management provides leadership, management, oversight, and assessment of all aspects of management and is responsible for managing overall utilization while ensuring delivery of essential services that address the total health care needs of The Health ...
-
Project Manager Digitalization
4 days ago
Nexus Innovations Belmont, OH, United States Freelance**Job Description**: · At Volkswagen Group Services GmbH in Wolfsburg, Germany, we are looking for a Digitalization Project Manager (m/f/d) to join our team. Our goal is to achieve a Smart Factory within the Volkswagen Group, enabling efficient and innovative production processes ...
-
Department Head Vz
4 days ago
Infinity Systems Martinsville, OH, United States Freelance**At our location in Putzbrunn, we are looking for a full-time (39 hours) department manager starting from ** · **We offer:** · - **In addition to the base salary: overtime, night, and weekend allowances** · - **Use of company apartments for 241€ rent per month** · - **Urban area ...
-
Nexus Innovations Glencoe, OH, United States FreelanceAt accilium, we are a management consultancy working with top clients in the Automotive & Transport, Energy & Environment, and Public & Infrastructure sectors to shape the future of mobility. Using digital transformation tools, we guide established companies into the future and s ...
-
Production Scheduler
1 week ago
MAHLE Belmont, United StatesJob Summary: · We are seeking a detail-oriented Production Scheduler to join our team. The Production Scheduler will be responsible for coordinating and planning production schedules to meet customer demands efficiently. · **Responsibilities**: · - Develop and maintain production ...
-
Used Car Buyer
2 weeks ago
Sonic Automotive Belmont, United States**Company Description** You're serious about your career**, and rest assured you've come to the right place. At **Autobahn Motors**, a Sonic Automotive family dealership, you'll find the opportunities, resources, and support you need to grow and develop professionally. Our 100+ d ...
-
Warehouse/forklift Operator
1 week ago
FBM-Foundation Building Materials Belmont, United StatesJob Overview: · We are seeking a Forklift Operator to join our team at a drywall distribution warehouse. Experience is welcome but not necessary. · **Duties**: · - Operate forklifts and other heavy machinery to move materials within the warehouse · - Perform routine maintenance c ...
-
Salesperson (Used Sales) - Autobahn Motors
3 weeks ago
Sonic Automotive Belmont, United States**Company Description** · At **Autobahn Motors**,** a Sonic Automotive family dealership, you'll find the opportunities, resources, and support you need to grow and develop professionally. Our 100+ dealerships are concerned with more than moving inventory; they're committed to yo ...
-
Automotive Office Manager
2 weeks ago
Grieco Automotive Group Smithfield, United StatesOverview: · The Grieco Automotive Group is looking for an Automotive Office manager or Controller to help with day-to-day functions at the corporate office in Smithfield RI. This is a corporate roll with a Great opportunity to advance with a growing company. · MUST HAVE AUTOMOTIV ...
-
Director of Facilities
2 weeks ago
Seternity Solutions Smithfield, United StatesOur director will lead budget reporting, CAPEX Planning maintain consistent client interaction with our Campus Finance team to provide detail-oriented oversight of the day-to-day operations with the Facilities team. · - Strong technical knowledge of the following: mechanical, ele ...
-
Registered Nurse, RN
3 weeks ago
BAYADA Home Health Care Smithfield, United States Full timeBAYADA Home Health is looking for compassionate and dedicated Registered Nurses (RN) to join our team part time in our Raleigh, North Carolina office. · This office services our adult and geriatric clients on a per visit basis in territories throughout Johnson County - Smithfiel ...
-
Licensed Practical Nurse
2 weeks ago
Rehabilitation Hospital of Rhode Island North Smithfield, United States Full timeDescription · A career at Rehabilitation Hospital of Rhode Island, a 20-bed inpatient acute rehabilitation hospital operated jointly with Lifepoint Health and Landmark Medical Center, is more than a job. It's a chance to be a vital member of an interdisciplinary team caring of pe ...
-
Licensed Practical Nurse
2 weeks ago
Rehabilitation Hospital of Rhode Island North Smithfield, United States Full timeDescription · A career at Rehabilitation Hospital of Rhode Island, a 20-bed inpatient acute rehabilitation hospital operated jointly with Lifepoint Health and Landmark Medical Center, is more than a job. It's a chance to be a vital member of an interdisciplinary team caring of pe ...
-
Director of Facilities
3 weeks ago
LucraLink Talent Solutions North Smithfield, United States**Job Overview**: · Client services include fully integrated facilities from grounds and custodial services to operations. This role will report directly to the District Manager, and our leader will be responsible for managing the budget and our team, overseeing performance to ac ...
-
Mental Health Tech, Nights
2 weeks ago
McLean Hospital(MCL) Belmont, United States**Mental Health Tech, Nights -Bipolar/Schizophrenic** · McLean Hospital is a comprehensive psychiatric hospital committed to providing easy access to superior quality, cost-effective mental health services in the Boston area, Massachusetts and beyond. Since 1811, McLean Hospital ...
-
Mental Health Tech 40 HR Nights
3 weeks ago
McLean Hospital(MCL) Belmont, United States**Mental Health Tech 40 hr Nights** · McLean Hospital is a comprehensive psychiatric hospital committed to providing easy access to superior quality, cost-effective mental health services in the Boston area, Massachusetts and beyond. Since 1811, McLean Hospital has been a world l ...
-
Mental Health Tech, Per Diem- Older Adult
3 weeks ago
McLean Hospital(MCL) Belmont, United States**Mental Health Tech, Per diem · - Older Adult** · McLean Hospital is a comprehensive psychiatric hospital committed to providing easy access to superior quality, cost-effective mental health services in the Boston area, Massachusetts and beyond. Since 1811, McLean Hospital has b ...
-
Mental Health Tech, 24 Hour
1 week ago
McLean Hospital(MCL) Belmont, United States**Mental Health Tech, 24 Hour - Alcohol and Drug Tx** · McLean Hospital is a comprehensive psychiatric hospital committed to providing easy access to superior quality, cost-effective mental health services in the Boston area, Massachusetts and beyond. Since 1811, McLean Hospital ...
-
Mental Health Tech 32 D/e Bipolar/schizophrenic
3 weeks ago
McLean Hospital(MCL) Belmont, United States**Mental Health Tech 32 D/E Bipolar/Schizophrenic** · McLean Hospital is a comprehensive psychiatric hospital committed to providing easy access to superior quality, cost-effective mental health services in the Boston area, Massachusetts and beyond. Since 1811, McLean Hospital ha ...
-
Mental Health Tech 32 D/e Bipolar/schizophrenic
3 weeks ago
McLean Hospital(MCL) Belmont, United States**Mental Health Tech 32 D/E Bipolar/Schizophrenic** · McLean Hospital is a comprehensive psychiatric hospital committed to providing easy access to superior quality, cost-effective mental health services in the Boston area, Massachusetts and beyond. Since 1811, McLean Hospital ha ...
Director, Utilization Management - Wheeling, United States - The Health Plan of West Virginia Inc
Description
Job Description
Job DescriptionThe Director of Utilization Management provides leadership, management, oversight, and assessment of all aspects of management and is responsible for managing overall utilization while ensuring delivery of essential services that address the total health care needs of The Health Plan members. The Director of UM works collaboratively with the Chief Medical Officer, Vice President of Medical Economics, Program Evaluation and Clinical Strategic Initiatives, Director of Case Management and Medical Directors, as well as other leaders to plan, organize, coordinate, develop the vision, perform implementation and measure the outcomes of all UM and A/G programs based on both governmental and non-governmental lines of business to ensure compliance to the requirements of all regulatory and accreditation bodies relevant to clinical management.
Required:
Desired:
Responsibilities:
&v=024){kind=logo}