The Sr. Manager, Utilization Management is responsible for managing clinical and non-clinical team members. May oversee complex case management, concurrent review, prior authorization, call center and or letter teams. Identifies, implements, and evaluates relevant performance metrics that allow for objective evaluation of staff and/or departmental performance. Responsible for monitoring and facilitating the attainment of performance metrics to meet departmental expectations for productivity and quality. Responsible for managing staffing requirements for daily workload and auditing of letters to comply with all regulatory requirements. Complete deliverables within established time lines. Responsible to ensure the auditing of staff monthly, and as needed to maintain compliance with state, federal and accreditation requirements. Facilitates clinical rounds and recommends training as needed. Ensures that organizational and departmental goals, as identified in Department's annual Business Plan, including specific departmental process improvement plans are met. Serves as the subject matter expert for assigned line of business. Acts as a department liaison/project manager on initiatives where collaboration is required for departmental and organizational goal attainment. In collaboration with the UM trainer (s) is responsible for staff onboarding. Responsible for staff development and performance management. Trouble shoots and investigates authorization issues as needed. Manages the staffing needs by reviewing analytic reports for productivity, pended cases, and average admissions per facility etc. Participates in workgroups across the organization and makes recommendations for improvement. Complete deliverables within established time lines. Actively fosters and engage in efforts to ensure a culture of collaboration and teamwork within Community's Leadership as well as with all internal and external partners. Supports organizational goals as outlined in the program description. Demonstrates Harris Health and Community Health Choice values, including trust, integrity, mutual respect, diversity, responsiveness and caring service. Complete other duties as assigned by the Director of Utilization Management and SVP Medical Affairs.
RN required, Bachelors degree in Nursing (BSN) preferred. Current, unrestricted license in the state of Texas, Master of Business Administration (MBA), Master of Health Administration (MHA) and/or Master of Science in Nursing (MSN) preferred. Experience in Medicaid and/or Commercial lines of business
Understand the Utilization Review process including census management
Experienced with medical necessity guidelines including MCG guidelines and/or Interqual guidelines
Three - five years of managed care experience
Three - five years of supervisory or leadership experience.
Above Average Verbal (Heavy Public Contact)
Above average Writing /Composing/ Correspondence /Reports
Ability to work autonomously, self-motivated, critical thinker, solution oriented, ability to perform at a high level under pressure and short deadlines.
Internal Number: 144937
About Harris Health System
The Harris Health System is a fully integrated healthcare system that cares for all residents of Harris County, Texas. We are the first accredited healthcare institution in Harris County to be designated by the National Committee for Quality Assurance as a Patient-Centered Medical Home, and are one of the largest systems in the country to achieve the quality standard. Our system includes 23 community health centers, five school-based clinics, a dental center and dialysis center, mobile health units, a rehabilitation and specialty hospital and two full-service hospitals.Ben Taub Hospital is a world renowned Level I Trauma Center with 586 licensed acute-care beds and provides a wide range of specialty care outpatient services. Lyndon B. Johnson Hospital is a 328 licensed bed acute-care hospital with a newly expanded Level III trauma center and a distinguished regional center for neonatal intensive care for high-risk deliveries.Harris Health is a teaching system for Baylor College of Medicine and The University of Texas Health Science Center at Houston (UTHealth). We train the next generation of healthcare providers on the latest medical procedures and technological breakthroughs.With... our fully integrated electronic medical records system, we offer patients the convenience and assurance that their medical history is accurate, safe and available when and where it is needed. Our Medical Home designation ensures that we offer a full range of preventive, specialty and acute care services for the entire family.