Supervisor Utilization Review

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Position Summary
 

The Supervisor is responsible for day-to-day operations of the utilization review team, which includes clinical and non-clinical staff, in the areas of referral and authorization requests, organizational determinations/ disputes, and auditing/training of utilization review staff. Regularly monitors daily workload, volumes, metrics, production, and phone queues. The Supervisor also ensures compliance with regulatory requirements, benefit interpretation, professional standards of practice, and timeliness and notification standards for all lines of business are met.

As an active member of the Health Plan leadership team, the Supervisor will serve as a subject matter expert with specific focus on mentoring new team members, assisting with training and development, and providing guidance and support.

Job Description

Key Outcomes:

• Leads daily team huddles and manages the day-to-day utilization review activities including referral/authorization requests and organization determinations. Monitors staff productivity and performance metrics and outcomes to ensure a productive and efficient team that meets all service and timeline standards.
• Serves as a mentor and daily resource for team members and partner departments assisting with questions, complex cases or situations and escalates as appropriate.
• Oversees initial and cross-training of utilization review team members on new programs and initiatives.
• Assists with onboarding new team members and provides support to the assigned preceptor.
• Assists with the creation and maintenance of utilization review standard work, guidelines, and job aids.
• Participates in program planning and enhancements. Identifies improvement opportunities and participates in technology, system planning and enhancement; recommends and tracks technology modifications that support the utilization review processes.

• Assists in performing utilization reviews in a clinical capacity.
• May serve as a clinical department representative in Health Plan committees, focus groups, and other strategic and operational interdepartmental initiatives.
• Ensures compliance with and integrity of all departmental processes and policies, benefit interpretation and professional standards of practice, and maintains a detailed knowledge of applicable regulatory and accrediting body standards (i.e. American Nurses Association (ANA), American Board of Managed Care Nursing (ABMCN), National Committee of Quality Assurance (NCQA), Centers of Medicare and Medicaid Services (CMS)) and assists all staff members to maintain compliance.

Education/Experience:

• Associates degree in nursing; Bachelor’s degree (BSN) preferred
• 3 years of medical management experience in a managed care setting including utilization review
• RN experience in a clinical setting required
• Leadership and/or management experience preferred

Required License(s) and/or Certification(s):

• Current Licensure as an RN in Maine and other appropriate jurisdictions as necessary
• Certification in Managed Care Nursing preferred

Skills/Knowledge/Competencies (Behaviors):

• Demonstrates an understanding of and alignment with Martin’s Point Values
• Excellent interpersonal, verbal, and written communication skills
• Critical thinking: can identify root causes and implement creative solutions; analyze and apply data to inform decision-making
• Ability to demonstrate a clear understanding of the standards of professional practice in decisions, leadership, and documentation
• Ability to prioritize time and manage multiple competing demands efficiently and effectively for self and others
• Ability to function independently
• Computer proficiency in Microsoft Office products including Word, Excel, and Outlook

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org