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Job Summary

The Supervisor Utilization Management - Government Programs provides leadership and oversight to the utilization management team, ensuring day-to-day activities align with timelines and quality standards. The key responsibilities for this role involve monitoring utilization review activities and outcomes and staff oversight.

Requirements

EDUCATION

Associate's degree in Nursing required.

Bachelor's degree in Nursing preferred. In lieu of degree, five (5) years' clinical experience required.

LICENSING/CERTIFICATION

Registered Nurse with current, unrestricted, licensure required for state of Arkansas or multistate licensure.

KNOWLEDGE & EXPERIENCE

Minimum five (5) years' Clinical experience with minimum two (2) years' experience in Utilization Management and Managed Care required OR applicable Masters in related field with minimum three (3) years' experience.

Minimum two (2) years' Government programs experience in Medicaid, Medicare and/or Federal Government Programs.

Demonstrated success as an individual contributor in current or related operational/functional area.

Experience working in regulatory and compliance requirements strongly preferred.

Experience with Milliman or InterQual guidelines preferred.

Skills

• Active Learning • Coaching Others • Cross-Functional Communications • Decision Making • Employee Engagement Strategies • Evaluating Information • Interpersonal Relationships • Management Techniques • Monitor Processes, Materials, or Surroundings • Oral Communications • Problem Solving • Researching • Service Oriented • Written Communication

Responsibilities

• Collaborates with hospital staff, care coordinators, and plan leadership to ensure members receive the appropriate level of care. • Communicates directly with appropriate internal staff regarding inpatient cases and outpatient/ambulatory requests not meeting medical necessity requirements and out of network transfer issues. • Contributes to program goals and objectives focused on cost containment and maintains a high-quality medical delivery system. • Ensures continuity of care for inpatients through early discharge planning and collaborating with hospital and health plan staff to identify home care candidates or less restrictive care options. • Ensures safe transitions to outpatient settings by improving self-management skills and addressing members psychosocial and non-medical needs. • Identifies and manages high risk members by collaborating with Case Managers to coordinate post-discharge care, ensuring timely outpatient follow-up, adherence to treatment plans, and proper medication and service implementation. • Maintains and submits reports and logs on review activities per standard operating procedures. • Maintains compliance with state mandated regulations. • Manages staffing logistics, specifically preparing schedules, assigning work, and adapting to changing priorities to meet both internal and external demands. • Performs other duties as assigned. • Performs utilization management and concurrent review for hospitalized members. • Supervises the hiring, coaching/training, employee development and performance management of Utilization Management team.

Certifications

Registered Nurse (RN) - Arkansas State Board of Nursing

Security Requirements

This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties

Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

Employment Type

Regular

ADA Requirements

1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting and routinely travels for work within walking distance of location of primary work assignment.