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About The Role

The Manager, Utilization Management (UM) will manage the Utilization Management team consisting of Clinicians and Non-Clinical support staff. The ideal candidate will have a strong clinical background within a managed care setting including a high-level understanding of prior authorization processes including inpatient/concurrent reviews, outpatient, and retrospective reviews.

Primary Responsibilities

+ Coordinate day to day operations of the Utilization Management team.

+ Serve as the primary contact for day-to-day operational escalations related to the Utilization Management program.

+ Establish and maintain positive intradepartmental and client relationships (i.e. account management, claims, customer service, intake…).

+ Contribute to development and maintenance of Utilization Management policies, standard operating procedures, and job aids that align with regulatory requirements.

+ Perform timely reviews of Utilization Management policies, standard operating procedures, and job aids to ensure accuracy and alignment with regulatory requirements.

+ Facilitate training for UM team members including Nurses and Coordinators on systems, departmental processes, and policies.

+ Facilitate ongoing quality oversight, education and performance improvement for team members.

+ Partner with Clinical Program leaders to address audit results to ensure compliance with regulatory and internal policy requirements.

+ Identify, solution, and implement new initiatives to improve the Utilization Management workflow. This may include intradepartmental collaboration and alignment across functional teams.

+ Responsible for addressing internal and client escalations as needed to the Director of Clinical Programs and VP of Clinical Operations.

+ Conduct routine team meetings.

+ Perform routine 1:1 discussion with individual staff members providing performance feedback throughout the year with the purpose of proactively addressing proficiency, competency, quality of documentation and understanding of expectations.

+ Support the development of downstream leaders through mentoring and training.

+ Other duties as assigned.

Essential Qualifications

+ Active and unrestricted license as a Registered Nurse (RN)

+ Bachelor’s degree in nursing, (or equivalent experience within managed care environment)

+ 5 or more years of professional experience, including 3+ years in Utilization Management leadership experience.

+ Experience with accreditation organizations (URAQ/NCQA)

+ Organized with the ability to define and solve problems, collect data, establish facts, follow-up, and make recommendations for current and future needs.

+ Strong team and leadership skills

+ Must be detail oriented and have strong organizational and time management skills, and the ability to work independently.

+ Proficient in Microsoft Word, Excel, and Outlook.

Preferred Qualifications

+ Prior Experience with leadership including Hiring, WFM, Staff Performance.

+ Experience working within a TPA environment.

+ Experience with Case Management

+ Familiarity with call center operations

+ Experience in health platform build and implementation.

*General Knowledge of HIPAA Confidentiality Laws

About

At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion, and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all your unique abilities.

Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes, and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions. Come be a part of the Brightest Ideas in Healthcare™.

Company Mission

Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

Company Vision

Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.

DEI Purpose Statement

At BHPS, we encourage all team members to bring your authentic selves to work with all your unique abilities.   We respect how you experience the world and welcome you to bring the fullness of your lived experience into the workplace.  We are building, nurturing, and embracing a culture focused on increasing diversity, inclusion and a sense of belonging at every level.

*We are an Equal Opportunity Employer

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