Supervisor, Utilization Management - Phoenix, United States - TriWest Healthcare Alliance

TriWest Healthcare Alliance

Verified Company

Phoenix, United States

1 week ago

Posted by:

Mark Lane

beBee recruiter

Description

Profile:

Veterans, Reservists, Guardsmen and military family members are encouraged to apply

We offer remote work opportunities (AK, AR, AZ, CA, *CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TX, UT, VA/DC, *WA, WI & WY only)

Job Summary
Supervises daily Utilization Management (UM) program operations.

This position reports to a Manager of Utilization Management in either Prospective, Retrospective, or Appeals and Reconsideration for the TRICARE contract.

The supervisor coordinates across teams to support meeting contractual metrics and timeliness, standardized clinical care requirements and accreditation standards. This position is responsible for supervision of UM performance and staff management. Development and preparation of operational reports. Functions as backup for staff during high volume periods.

Education & Experience

Required:

Registered Nurse, with current valid, unrestricted nursing license
3+ years of job related experience in a healthcare environment
3+ years supervisory or leadership experience in a healthcare environment
2+ years utilization review or case management
U.S. Citizenship
Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation

Preferred:

Medical/Surgical or Behavioral Health experience
Commercial Managed Care experience
Knowledge of government health care programs
Familiarity with utilization review criteria
CCM or HCQM certification
Knowledge of medical billing and coding
Prior experience with remote work environments

Key Responsibilities

Supervises day to day UM operations to ensure operational effectiveness and efficiency.
Ensures staff is fullyinformed of changes by communicating updates, policy revisions, performance outcomes, and significant events.
Monitors staff to ensure adherence to established criteria, including InterQyal, internally developed guidelines, decision support tools, contract requirements and TriWest policies and desk procedures.
Prepares reports for tracking and trending of UM activities.
Interprets reports and identifies UM opportunities to share with management.
Monitors the UM process and identifies and implements process improvements to ensure program quality assurance and compliance.
Reports Potential Quality Issues (PQI).
Responsible for interviewing and hiring new staff.
Provides coaching and oversight to staff to ensure staff success and development.
Assists with implementation, orientation and training of new staff.
Assists with the development of desk procedures, processes, workflow changes, and reports.
Systematically evaluates the quality and effectiveness of staff performance.
Advises and coaches when appropriate and completes annual performance appraisals.
Participates in meetings as required.
Collaborates across the clinical operations team for enhancing service levels.
Coordinates activities with contracted partners to meet Utilization Management (UM) Plan goals.
Completes special projects.
Regular and reliable attendance.
Performs other duties as assigned.

Competencies

Coaching / Training / Mentoring:
Actively foster actions required for desired business outcomes through ongoing constructive feedback.

Communication / People Skills:
Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.

Coping / Flexibility:

Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.

Delegation Skills:
Provide clear performance expectations for projects and ensure adequate access to resources for completion

Independent Thinking / Self-Initiative:

Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources.

Information Management:
Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions.

Leadership:
Successfully manage different styles of employees; provide clear direction and effective coaching.

Multi-Tasking / Time Management:
Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment.

Organizational Skills:

Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources, detail oriented.

Problem Solving / Analysis:
Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues.

Team-Building / Team Player:
Influence the actions and opinions of others in a positive direction and build group commitment.

Working Conditions

Working Conditions: