Job Description

JOB SUMMARY:
The Manager of Utilization Management develops, administers and maintains programs and activities specific to utilization management for inpatient and outpatient services for Health Alliance and its partners. The manager is responsible for oversight and resource allocation for utilization management activities in order to coordinate and manage the most effective use of healthcare resources. The manager promotes ongoing quality of care and services by adhering to Accrediting Body standards; and responsible for ensuring compliance with all regulatory requirements. The manager maintains consistency of plan administration across all health plan service areas.

EDUCATIONAL REQUIREMENTS
Bachelors in Nursing

CERTIFICATION & LICENSURE REQUIREMENTS
Registered Professional Nurse (RN) License Illinois upon hire.

EXPERIENCE REQUIREMENTS
Five (5) Healthcare/Medical - Acute Care and Two (2) Managed Care and Nursing and management experience in a healthcare or managed care setting.

SKILLS AND KNOWLEDGE
Leadership, organization, and planning skills; the ability to communicate effectively and work collaboratively with medical, administrative, and support staff; the ability to project a positive image of Health Alliance; the ability to make independent decisions, direct, plan and implement new policies and procedures, and accept change; availability for flexible work hours, on call accessibility and travel to affiliate locations.

ESSENTIAL FUNCTIONS:

• Manages UM operations and ensures standards of quality and service are provided in accordance with organizational goals and priorities
• Assumes responsibility for personnel related duties that include interviewing, disciplinary actions, payroll reporting, scheduling paid leave, and enforcing required rules and regulations
• Monitors employee performance and ensures timely communications for the purpose of goal setting, performance evaluations, wages increases and continued personnel actions
• Participates in the assessment, development, implementation, maintenance and enhancement of computer supported data systems to assure documentation of information promotes a high performing team
• Responsible to assist in the planning and implementing of rules and regulations to ensure compliance with accrediting and regulatory bodies
• Develops and maintains beneficial working relationships with internal and external customers
• Responsible for identifying and resolving cost-effective, quality care issues in utilization management to achieve competitive advantage in the managed care industry
• Acts as a content expert to the Medical Management Division and to all other departments