Manager, Utilization Management - MSL/RN - Behavioral Health at CareSource

Dayton, Ohio, United States -

Full Time

Start Date

Immediate

Expiry Date

02 May, 26

Salary

132800.0

Posted On

01 Feb, 26

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Utilization Management, Behavioral Health, Data Analysis, Communication Skills, Leadership Skills, Attention to Detail, Critical Thinking, Time Management, Customer Service, Decision Making, Problem Solving, Training Skills, Negotiation Skills, Technical Writing, Excel, Word

Industry

Insurance

Description

Job Summary: The Manager, Utilization Management Behavioral Health is responsible for the oversight of all behavioral health utilization management activities ensuring consistency of services and achievement of utilization targets. Essential Functions: Assist in coordination and management of the pre-determination process of behavioral health services; ensure the consistent application of criteria for authorization decision, and that decisions to deny or reduce services are made by a health care professional who has appropriate clinical expertise Assist in the development of integrated service delivery to members and oversee behavioral health utilization management data and processes to maintain industry standards and practices including decisions within allowable timeframes Interact with providers and staff to manage benefits aligned with state-based regulations, NCQA and/or URAC regulations, and CareSource policies Review and revise workflows to maximize efficiencies Monitor productivity and utilization trends Oversee CQI activities and ensure audits and staff feedback occur at regular intervals Regularly report all utilization management regulatory requirements Ensure compliance with and reporting of all regulatory requirements Maintain all behavioral health utilization management reporting and trend data Analyze under and over utilization information for impact on member quality of care and outcomes and formulate recommendations based on data Develop, maintain and update all departmental policies and procedures; ensure notices of adverse action are provided in accordance with required regulations Audit predetermination requests, cases for documentation and interrater reliability per CareSource policy Act as liaison with other departments to assist with research and intervention Performs any other job related duties as requested. Education and Experience: Associates degree in Nursing, behavioral health or related field required Bachelor's Bachelor's degree preferred Equivalent years of relevant work experience may be accepted in lieu of required education Five (5) years of clinical experience required Five (5) years of experience in one of the following: behavioral health, case management, utilization management, and/or quality improvement required Two (2) years utilization management experience preferred Managed Care experience preferred One (1) year Leadership experience required Competencies, Knowledge and Skills: Beginning Excel, Word and PowerPoint experience Experience in data analysis and trending Knowledge of utilization management standards and practices Communication skills Management and prior supervisory skills Ability to work independently and within a team environment Attention to detail Familiarity of the health care field Critical listening and thinking skills Training/teaching skills Strategic management skills Negotiation skills/experience Proper grammar usage Change resiliency Technical writing skills Time management skills Proper phone etiquette Customer service oriented Decision making/problem solving skills Leadership experience and skills Licensure and Certification: Current, unrestricted licensure in state of practice as a Registered Nurse (RN), Licensed Social Worker (LSW), Psychologist, or Professional Clinical Counselor (PCC) required Working Conditions: General office environment; may be required to sit or stand for extended periods of time Travel is not typically required Compensation Range: $83,000.00 - $132,800.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Salary Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-JM1 The CareSource mission is known as our heartbeat. Just as we support our members to be the best version of themselves, our employees are driven by our mission to create a better world for members, stakeholders and providers. We are difference-makers who combine compassionate hearts with our unique business expertise to make every opportunity count. Each claim, each phone call, each consumer-centric decision is a chance to change the world for one member, and our employees look for ways to do that every day. The challenge is, there is no one right way to be the difference and we’re looking for people like you that will rewrite that definition every day. We do what it takes to form creative solutions that make our community and the world just a little better. Discover what it means to be #UniquelyCareSource.

Responsibilities

The Manager, Utilization Management Behavioral Health oversees all behavioral health utilization management activities, ensuring consistency of services and achievement of utilization targets. This includes managing the pre-determination process, interacting with providers, and ensuring compliance with regulatory requirements.