Utilization Management Process Manager

We're excited about the potential people bring to our organization. You can grow your career here while enjoying first-class perks, benefits and a culture that fosters growth, innovation and collaboration.

The Utilization Management (UM) Process Manager will be accountable for the development, management, implementation, communication, revision and execution of the UM review process, medical necessity policy and procedure development. They will identify and draft necessary changes in medical and administrative policy, including use and maintenance of MCG clinical criteria, the MCG Guideline Modification tool, MCG Transparency tool and daily UM review process all within the confines of regulations governing medical necessity criteria including but not limited to CMS, NCQA/URAC and New York State Insurance law. In addition, they will be responsible for identifying recommended changes to the UM Medical Management processes and seeking approval from Heathcare Services leadership to lead implementation throughout the UM department as it relates to pre-service, concurrent and retrospective review.

The Process Manager will ensure accurate implementation, system configuration and appropriate application of the use of medical necessity criteria and UM processes. They will work collaboratively with and influence multiple departments to continually assess and make recommendations for improvements to maintain an effective and efficient utilization management process, as well as configuration and maintenance of guideline modifications. The Process Manager will be responsible for assessing and communicating efficiency gains in UM process revision and adjusting when necessary.

• Bachelor's degree required. An additional four (4) years of experience will be considered in lieu of degree.

• Five (5) years of experience in health plan managed care operations required; experience as a UM review nurse preferred.
• Current, active, unrestricted and licensed registered nurse (RN) preferred.
• Certified MCG specialist preferred.
• Knowledge of clinical care management processes, member benefit structures and applications, and claims processing.
• Knowledge of medical necessity criteria development, claims systems, clinical platforms and/or CRM applications.
• Prior experience with MCG and the MCG Modification tool functionality.
• Ability to define processes problems, analyze data/information and critically think through UM process scenarios.
• Knowledge and experience in development of clinical processes.
• Knowledge of ICD-10, CPT and HCPCS coding.
• Knowledge of program implementation with project management approach.
• Excellent verbal, written and interpersonal communications skills required with emphasis on diplomacy, negotiation, persuasiveness and interaction with multiple levels of management.
• Ability to work independently and lead or participate on multi-disciplinary project teams.
• Excellent time management and organizational skills.
• Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative and Accountable.

• Identify areas of optimization within the UM process, develop and implement strategies for improvement and monitor the effectiveness of changes.
• Stay abreast of new clinical technology, treatments, testing and trends in the market to ensure medical necessity criteria are current and competitive within industry.
• Contribute to the development, implementation and maintenance of UM medical necessity policy and procedures ensuring compliance with regulatory requirements and industry best practice.
• Optimize existing policy as it relates to medical management and utilization management by monitoring services subject to medical necessity review and implementing UM process revision as needed.
• Obtain approval for any changes from the Medical Director and governing committee(s) and oversee the implementation throughout the organization (systemically, procedurally and communication).
• Assess IH medical criteria vs MCG to define best practice use of criteria.
• Evaluate and maintain annual evaluation of all medical necessity criteria.
• Develop and maintain medical necessity criteria utilizing evidence-based literature.
• Work collaboratively with multiple departments to continually assess and make recommendations for improvements to maintain an effective and efficient utilization management process and manage medical expenses based on trends.
• Manage and support HCS team with regards to implementation and communication (internal and external) of new medical management processes.
• Work collaboratively with training resources to ensure all medical management staff are updated on new UM processes.
• Develop processes for the creation, tracking, and reporting of all benefit management changes within the medical management department.
• Maintain UM review requirements and ensure implementation of any approved changes.
• Provide application systems expertise to client communities.

Immigration or work visa sponsorship will not be provided for this position

Hiring Compensation Range: $85,000 - $105,000 annually

Compensation may vary based on factors including but not limited to skills, education, location and experience.

In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off. The base salary range is subject to change and may be modified in the future.

As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant's race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law. Click here for additional EEO/AAP or Reasonable Accommodation information.

Current Associates must apply internally via the Job Hub app.