Supervisor, Utilization Management

COMPANY OVERVIEW:

HealthAxis is a prominent provider of core administrative processing system (CAPS) technology, business process as a service (BPaaS), and business process outsourcing (BPO) capabilities to healthcare payers, risk-bearing providers, and third-party administrators. We are transforming the way healthcare is administered by providing innovative technology and services that uniquely solve critical healthcare payer challenges negatively impacting member and provider experiences.

We live and work with purpose, care about others, act with integrity, communicate with transparency, and don’t take ourselves too seriously.

We're not just about business – we're about people. Our commitment to a people-first approach shapes everything we do, from collaborating as a team to serving our valued clients. We believe that creating a vibrant and human-centric environment can inspire engagement, empower our team members, and ignite a sense of purpose in all that we accomplish.

PURPOSE AND SCOPE:

The Utilization Management Supervisor is responsible for the day-to-day operations of the Utilization Management Department.  The supervisor functions are responsible for outpatient prior authorization teams and inpatient acute/subacute teams.  This role fosters an atmosphere of teamwork and ensures healthcare services are authorized efficiently, effectively, and in compliance with regulations.

PRINCIPAL RESPONSIBILITIES AND DUTIES:

• Lead and coach utilization management (UM) licensed staff, coordinators, and support staff

• Ensure prior authorization determinations meet regulatory and contractual service level agreements (SLA’s)

• Monitor key performance indicators (i.e., turnaround times and SLA’s) and quality of reviews

• Perform outpatient and inpatient prior authorizations based on work volume and staffing ratios

• Manage inventory to adhere to strict CMS timeliness requirements

• Oversee daily inventory and assign tasks, ensuring effective workforce management

• Monitor staff productivity and achievement of performance objectives, coach to performance

• Develop and deliver training program for UM staff; ensure ongoing quality performance

• Communicate with clients, providers, and Medical Director regarding organization determinations, explaining the rational for decisions, or coordinating complex cases

• Manage escalated cases or client inquiries regarding prior authorizations

• Collaborate with UM Manager and Medical Director on process improvements, initiatives, and regulatory updates

• Continuously assess processes to optimize resource use

• Develop job aids and tools to enhance efficiency

• Ensure the achievement of departmental quality improvement goals

• Perform additional duties as assigned by the Health Services management

CUSTOMER SERVICE:

• Responsible for driving the HealthOP’s culture through values and customer service standards

• Accountable for outstanding customer service to all external and internal contacts

• Develops and maintains positive relationships through effective and timely communication

• Takes initiative and action to respond, resolve and follow up regarding customer service issues with all customers in a timely manner

EDUCATION, EXPERIENCE AND REQUIRED SKILLS:

• Minimum 5 years supervisory experience in utilization management /prior authorization

• Licensed RN (multi-state licensure preferred)

• Three to five years related Medicare/Medicaid, or commercial health plan, BPO, or TPA experience

• Three to five years of prior authorization experience (outpatient, inpatient initial and concurrent review)

• Excellent oral and written communication skills, with strong grammar, voice, and diction

• Able to read and interpret and understand documents accurately

• Proficient in MS Office with basic computer and keyboarding skills

• Strong investigative and critical thinking skills for addressing issues with internal and external clients

• Ability to build and lead a cohesive, high-performing team focused on delivering quality services

• In-depth knowledge of Medicare and Medicaid coverage criteria and compliance requirements

• Proficient knowledge and application of evidence-based decision support criteria (i.e., InterQual® preferred)

• Experience in discharge planning and care transition management