Location: Dublin,OH, USA
**Utilization Management Plan Oversight Manager (Ohio Resident)**
Location: Dublin, OH
Primary Job Function: Medical Management
ID**: 37872
**Job Brief**
Candidate must reside in Ohio. Will attend meetings and audits. Knowledge of Ohio Medicaid policies required. RN required
Your career starts now. We are looking for the next generation of health care leaders.
At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nations leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to hear you.
Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.
Discover more about us at www.amerihealthcaritas.com.
**Must be a resident of the State of Ohio.**
**Responsibilities:**
Reporting to the Chief Medical Officer for the Ohio Market, this position is representing Utilization Management (UM) in state interactions/audits, validation of regulatory reporting/analytics for UM OH, and serves as SME for clinical components of the OH Medicaid Utilization Management Program. Works in close collaboration with all departments to achieve regulatory standards and optimal departmental outcomes. Develops solutions that may consist of process improvements and/or system development components and are intended to optimize the functionality of the applications and related processes to support the business needs. Responsible for being final sign off for regulatory analytics validation. Analyzes the needs of the organization with the commitment to design and implement solutions that best support the needs of the business. This position will solicit ideas for systems improvements, review and present new system enhancements/features, and engage in continuous improvement planning, including testing and roll-out of configuration changes.
Qualified candidates will:
+ Have working knowledge of prior authorization, medical necessity determinations, concurrent review, retrospective review, continuity of care, care coordination, and other clinical and medical management programs.
+ Have working knowledge of all applicable statutory provisions, contracts and established policies and administrative procedures.
+ Serve as designee for LOB Quality Meetings, corporate UM meetings, state UM meetings and functions.
+ Assist in preparation, coordination, and participation in and follow up of Utilization Management audits, such as readiness review, Data Validation, CMS Program Audit and Compliance/Internal audits, pertaining to the OH Utilization Management program.
+ Act as a primary liaison with plan providers including but not limited to physicians, hospital delegates, provider office personnel and health care vendors.
+ Participate in coordination of internal and external Provider and Member directed communication regarding issues impacting OH Utilization Management coordination and delivery.
+ Develop OH specific content for training to ensure that all new and existing staff are oriented to organizational and department policies and procedures. Track that credential of all licensed staff are verified in accordance with OH licensing agency initially and prior to expiration date. Maintain current and accurate files of such licensure and ongoing education status. Track that staff meets minimal skill and clinical knowledge requirements to be successful in assigned role.
+ Maintain a current knowledge of company policy and procedures Medicaid Medical Necessity guidelines and InterQual criteria access and delivery of services.
+ Assist in the development of mitigation or remediation processes from any deficiencies in scheduled Performances Reviews, CMS audits, OH EQRO audits. Establish action plan for assessment and resolution of identified issues.
+ Participate in current process review and development of new and/or revised work processes, policies and procedures relating to OH Utilization Management responsibilities. Develop educational material and programs necessary to meet business objectives, members needs, OH contractual and regulatory guidelines and staff professional development.
+ Comply with Corporate, Federal, and State confidentiality standards to ensure the appropriate protection of member identifiable health information.
+ Other duties as assigned.
**Education/ Experience**
+ Bachelors Degree.
+ Current and unrestricted RN license in OH.
+ 3+ years of utilization/case management experience in relevant scope preferred, one year required.
+ 3+ years relevant clinical practice required.
+ Demonstrated ability to assess a departments work quality and develop/implement process improvements to achieve contractual and oversight compliance.
+ Experience managing multiple processes and being an influencer to facilitate change.
+ Demonstrated competency in use of healthcare data.
+ Understanding of managed care and impact on services including but not limited to, prior authorization, inpatient review, discharge planning, home health, and SNF/Rehabilitation Services.
**Other Skills:**
+ Strong organizational and prioritization skills.
+ Excellent analytical and problem-solving skills.
+ Strong computer skills including proficiency and speed working in all Microsoft Office Suite applications.
+ Understanding of and expertise in quality and process improvement.
+ Excellent/professional communication skills.
**Diversity, Equity, and Inclusion**
At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.
We keep our associates happy so they can focus on keeping our members healthy.
**Our Comprehensive Benefits Package**
Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.
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