Manager of Utilization Review

Denver, Colorado

Intro:

Are you an experienced Registered Nurse with Utilization Management experience looking for a new opportunity with a prestigious healthcare company? Do you want the chance to advance your career by joining a rapidly growing company? Are you passionate about helping others?  If you answered “yes” to any of these questions – this is the position for you!

Position Summary:

You, as the Manager of Utilization Review will utilize clinical knowledge and communication skills to obtain patient specific information regarding patient condition and proposed treatments and procedures to determine if illness and/or proposed services meet acceptable criteria sets and acceptable nursing practice guidelines for outpatient treatment or inpatient admission.  As the Manager of Utilization Review you will also review denial recommendations from the UM delegate and certify treatment meets clinical practice guidelines, in accordance with the health benefit plan, disability, workers compensation regulations, NCQA standards and state and federal regulations. It is also the responsibility of the Manager of Utilization Review to work with the Associate Medical Director to ensure denial recommendations are processed to meet clinical criteria as well as timeliness requirements to meet accreditation and regulatory statutes.

Hours for this Position:

Monday through Friday 8:00AM to 5:00PM

Advantages of this Opportunity:

• Competitive salary
• Fun and positive work environment

Required Skills

What We Look For:

• Licensed Registered Nurse with valid, unrestricted, current nursing license in the state or territory of the United States where employed
• 5+ years of utilization management experience with Milliman Care Guidelines and Interqual for medical necessity determination
• 5+ years of broad medical management leadership experience in a health insurance organization
• 3+ years of clinical experience
• Ability to identify, design, drive, and evaluate clinical care management programs, meet deadlines, and make changes as needed
• Ability to communicate and influence a variety of constituents
• Knowledge of health care cooperatives and their differentiation in the market
• Knowledge of Colorado’s health insurance market 

Responsibilities

More Insight of Daily Responsibilities: 

• Works with Chief Medical Officer, Chief Operating Officer, and Director of Technology to implement and provide oversight of clinical case management procedures with the CO-OP’s Third Party Administrator (TPA) vendor.
• Develops staffing and training plans for utilization management and disease management functions.
• Identifies and implements other strategies that insure quality care, access to care, and the financial success of the cooperative.
• Participates in appropriate meetings on health CO-OPs at the federal, state, and local levels, and with CO-OP national trade organizations to share information and identify best practices for our company.
• Plans and coordinates projects and tasks for NCQA accreditation related to file audit for UM processes.
• Demonstrates knowledge of NCQA guidelines, our company policies and procedures, and standards of practice and their revisions. Able to attain and maintain the minimal quality assurance performance standards.
• Demonstrates assertiveness in completion of precertification and concurrent review within the guidelines of NCQA, disability, workers compensation regulations, and state and federal requirements and according to the company’s policies and procedures.

Want More Information?

Interested in hearing more about this great opportunity? Reach out to Frank at fmullett@healthcaresupport.com for immediate consideration.

Why You Should Work For Us:

HealthCare Support Staffing, Inc. (HSS), is a proven industry-leading national healthcare recruiting and staffing firm. HSS has a proven history of placing talented healthcare professionals in clinical and non-clinical positions with some of the largest and most prestigious healthcare facilities including: Fortune 100 Health Plans, Mail Order Pharmacies, Medical Billing Centers, Hospitals, Laboratories, Surgery Centers, Private Practices, and many other healthcare facilities throughout the United States. HealthCare Support Staffing maintains strong relationships with top providers in healthcare and can assure healthcare professionals they will receive fast access to great career opportunities that best fit their expertise. Connect with one of our Professional Recruiting Consultants today to see how a conversation can turn into a long-lasting and rewarding career!

Salary

$70,000 +