Supervisor Utilization Review

Portland - USA

Monthly Salary: Not Disclosed

Posted on: 30+ days ago

Vacancies: 1 Vacancy

Job Summary

Join Martins Point Health Care - an innovative not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force ofpeople caring for people Martins Point employees are on amission to transform our health care system while creating a healthier community. Martins Point employees enjoy an organizational culture of trust and respect where our values - taking care of ourselves and others continuous learning helping each other and having fun - are brought to life every day. Join us and find out for yourself why Martins Point has been certified as a Great Place to Work since 2015.

Position Summary

The Supervisor is responsible for day-to-day operations of the utilization review team which includes clinical and non-clinical staff in the areas of referral and authorization requests organizational determinations/ disputes and auditing/training of utilization review staff. Regularly monitors daily workload volumes metrics production and phone queues. The Supervisor also ensures compliance with regulatory requirements benefit interpretation professional standards of practice and timeliness and notification standards for all lines of business are met.

As an active member of the Health Plan leadership team the Supervisor will serve as a subject matter expert with specific focus on mentoring new team members assisting with training and development and providing guidance and support.

Job Description

Key Outcomes:

Leads daily team huddles and manages the day-to-day utilization review activities including referral/authorization requests and organization determinations. Monitors staff productivity and performance metrics and outcomes to ensure a productive and efficient team that meets all service and timeline standards.
Serves as a mentor and daily resource for team members and partner departments assisting with questions complex cases or situations and escalates as appropriate.
Oversees initial and cross-training of utilization review team members on new programs and initiatives.
Assists with onboarding new team members and provides support to the assigned preceptor.
Assists with the creation and maintenance of utilization review standard work guidelines and job aids.
Participates in program planning and enhancements. Identifies improvement opportunities and participates in technology system planning and enhancement; recommends and tracks technology modifications that support the utilization review processes.

Assists in performing utilization reviews in a clinical capacity.
May serve as a clinical department representative in Health Plan committees focus groups and other strategic and operational interdepartmental initiatives.
Ensures compliance with and integrity of all departmental processes and policies benefit interpretation and professional standards of practice and maintains a detailed knowledge of applicable regulatory and accrediting body standards (i.e. American Nurses Association (ANA) American Board of Managed Care Nursing (ABMCN) National Committee of Quality Assurance (NCQA) Centers of Medicare and Medicaid Services (CMS)) and assists all staff members to maintain compliance.

Education/Experience:

Associates degree in nursing; Bachelors degree (BSN) preferred
3 years of medical management experience in a managed care setting including utilization review
RN experience in a clinical setting required
Leadership and/or management experience preferred

Required License(s) and/or Certification(s):

Current Licensure as an RN in Maine and other appropriate jurisdictions as necessary
Certification in Managed Care Nursing preferred

Skills/Knowledge/Competencies (Behaviors):

Demonstrates an understanding of and alignment with Martins Point Values
Excellent interpersonal verbal and written communication skills
Critical thinking: can identify root causes and implement creative solutions; analyze and apply data to inform decision-making
Ability to demonstrate a clear understanding of the standards of professional practice in decisions leadership and documentation
Ability to prioritize time and manage multiple competing demands efficiently and effectively for self and others
Ability to function independently
Computer proficiency in Microsoft Office products including Word Excel and Outlook

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

Do you have a question about careers at Martins Point Health Care Contact us at:

Required Experience:

Manager