Virginia Premier Health Plan Manager, Utilization Management in Chesapeake, Virginia
The Manager, Utilization Management is responsible for leadership and management of case and utilization management staff, including operational decisions, daily clinical decisions, process improvement, staff development, and compliance with Virginia Premier policies and procedures.
Supervises Utilization Management (UM) and other support staff according to Virginia Premier policy and procedures to assure that UR reviews and activities are accurate, consistent, and performed in a timely manner.
Assists with the development of UM staff onboarding and training programs.
Coaches staff and supports healthy team dynamics.
Serves in an advisory capacity for problem solving, reviewing reports being sent to internal and external customers, reviewing problematic cases, and monitor utilization management activities.
Review specialized reports to identify trends and opportunities for improvement to enhance relationships with the provider network and service to members.
Ensure requirements for auditing UM decisions, documentation and quality are being met.
Assists Director of UM with ongoing Quality Improvement Program by assisting with various quality review tasks such as collecting and analyzing data as outlined in the program.
Assists in the ongoing development of programs and medical management projects to enhance/expand the medical management department.
Maintains confidentiality of patient information, and Virginia Premier proprietary operational information.
Maintains current knowledge of Virginia Premier policies and procedures.
Participates in continuing education activities as appropriate.
Participates in community programs (which may occur outside of normal business hours).
This position provides services and demonstrates the knowledge and ability to meet the specific needs of all age groups
Other duties as assigned.
Registered Nurse licensed to practice nursing in Virginia
Utilization Management experience
SPECIAL KNOWLEDGE AND/OR SKILLS
Knowledge of evidence based criteria, such as Interqual.
Excellent problem solving skills
Patient assessment skills
Knowledge of community resources and vendor options, and experience in making appropriate referrals
Ability to negotiate with providers and vendors
Demonstrates excellent verbal and written communications
Demonstrates working knowledge of computers and word processing programs
Ability to build and support successful work teams
Possess knowledge of ICD-9 and CPT4 coding
Knowledge of Six Sigma Lean methodology or other Performance Improvement methodology
Minimum of 3 years utilization management experience, preferably in a managed care environment
Minimum of 1 year Management experience
Experience in clinical nursing
Experience working with low income disadvantaged populations.
- Physical health sufficient to meet the ergonomic standards and demands of the position.
Virginia Premier is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs. Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia.
We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.
Our mission is to inspire healthy living within the communities we serve!
Job Locations US-VA-Glen Allen
Job ID 2018-4539
As an equal opportunity employer, Virginia Premier is committed to a diverse workforce. To ensure non-discrimination and affirmative action for individuals protected by Executive Order 11246, as amended, Section 503 of the Rehabilitation Act of 1973, as amended, the Vietnam Veterans’ Readjustment Act of 1974, as amended, and Title I of the Americans with Disabilities Act of 1990, as amended, Virginia Premier will consider applicants for employment without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. Applicants who require accommodation in the job application process may contact Recruitment at 804-819-5151 for assistance. It is the policy of Virginia Premier Health Plan, Inc., to comply with the requirements of the Drug-Free Workplace Act of 1988. It is a violation of our drug-free workplace policy to use, possess, sell, trade, and/or offer for sale alcohol, illegal drugs or intoxicants in our workplace. Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. Virginia Premier participates in E-verify.