Utilization Management Director leads and directs the utilization review staff and function for a healthcare facility. Determines policies and procedures that incorporate best practices and ensure effective utilization reviews. Being a Utilization Management Director manages and monitors both concurrent reviews to ensure that the patient is getting the right care in a timely and cost-effective way and retrospective reviews after treatment has been completed. Provides analysis and reports of significant utilization trends, patterns, and impacts to resources. Additionally, Utilization Management Director consults with physicians and other professionals to develop improved utilization of effective and appropriate services. Requires a master's degree. Typically reports to top management. Typically requires Registered Nurse(RN). The Utilization Management Director manages a departmental sub-function within a broader departmental function. Creates functional strategies and specific objectives for the sub-function and develops budgets/policies/procedures to support the functional infrastructure. Deep knowledge of the managed sub-function and solid knowledge of the overall departmental function. To be a Utilization Management Director typically requires 5+ years of managerial experience. (Copyright 2024 Salary.com)
Department: Utilization Review-DC Medicaid
Status: Full-time, 40 hours per week, Non-exempt
Schedule: Monday-Friday, 9:00am-5:30pm
Must report on-site in office 1-2 times per week.
Job Summary:
Provides administrative and other support to the Clinical Operations team of MedStar Family Choice. including accurate and efficient management of incoming calls and faxes. Responsible for managing outgoing correspondences and special projects to support the Clinical Operations process.
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Primary Duties:
Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.
ACD Line management for the Clinical Operations Department.
Actively manages incoming calls to collect appropriate information, assesses and identifies caller needs with efficiency and/or to courteously direct the calls to the appropriate staff in a timely manner per MFC's guidelines.
Acts as a liaison to providers and members to communicate status of authorization decisions or need for additional information.
Assists with MedStar Family Choice (MFC) Clinical Operations initiatives. This may involve; completing outreach to members, assisting with scheduling appointments, and/or removing identified barriers for members. Investigation may be required to locate members. Works collaboratively with the case management staff, clinical staff, and providers to assist members with compliance.
Generates Local Health Department referrals and case management referrals when criteria are met. Assists with member surveys for case management programs.
Assists with special mailings when indicated for case management programs.
Demonstrates behavior consistent with MedStar Health mission, vision, goals, objectives and patient care philosophy.
Ensures complete communication (closes the loop and follow up) between key internal and external customers.
Enters data into the clinical software system related to pre-authorization requests for pharmacy, non-pharmacy, case management and hospitalizations.
Maintains timely and accurate documentation in the clinical documentation system.
Processes telephone inquiries and communicates accurate knowledge of benefits, policies and procedures.
Projects a positive image on the telephone to internal and external customers. Represents the best of MedStar Family Choice (MFC) at all times and to all customers.
Work collaboratively with the case management/ utilization management teams, and other customers internally and externally to meet the needs of the population.
Participates in meetings and on committees and represents the department and hospital in community outreach efforts.
Qualifications:
High School Diploma or GED required
6 months customer service experience in a managed care or social service setting required
Medicaid experience preferred
Knowledge of word processing, spreadsheet, database, and Microsoft PowerPoint
Effective verbal and written communication skills required