Manager, Utilization Management Operations (mostly remote)
: Job Details :

Reviews specific utilization issues or requests with Clinical Review team, focusing on problem solving, response to actual or potential quality issues or complaints, and/or approvals requiring next level authorization (e.g., utilization management, high cost services, out of network services, etc.). Investigates, analyzes, and reports to VNS Health Plans leadership on trends related to service requests and decisions, including recommendations regarding interventions and outcomes. Monitors and ensures that utilization management processes are followed by the service operations staff, utilization staff, and the interdisciplinary care team to ensure cost effective quality outcomes. Assures compliance with regulatory requirements and achievement of audit targets. Collaborates with Compliance department to ensure that all necessary corrective actions are enforced strictly and timely. Participates in development and implementation of the Quality Assurance and Compliance initiatives; collabor...Operations, Management, Manager, Operation, Remote, Staff, Healthcare