Manager, Utilization Management (Monday - Friday)

Utilization Management Director

Looking for a way to make an impact and help people?

Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

Manage daily operations, including supervision of Health Services Representatives and Clinicians involved in Utilization Management (UM) functions. Integrally involved in the Health Services (HS) program development, implementation, and strategic planning. Accountable for the success of PacificSource UM program development and performance measures, both internal and those established by regulatory entities.

Qualified candidates must be acceptable to the following available work schedule :

Monday - Friday 8 : 00am to 5 : 00pm

Essential Responsibilities :

• Work closely with the UM Director to facilitate the development and implementation of new programs and support ongoing success of department goals and initiatives.
• Responsible for oversight, management, development, implementation, and communication of department programs. Ensure PacificSource UM programs are communicated to and coordinated with our provider and community partners.
• Develop and oversee the Utilization Management process to ensure the review of medical appropriateness and / or acquiescence to the Oregon Prioritized List for proposed care of PacificSource members.
• Meet company policies, the best evidence-based medicine, and the policies of regulatory entities.
• Closely coordinate UM programs with other PacificSource Health Services departments, such as Care Management, Behavioral Health, Pharmacy Services, Quality Improvement, Provider Relations, Condition Support, Sales and Product Development.
• Collaborate and coordinate with the Compliance Department to ensure that all UM activity and reporting meet the requirements of all regulatory entities.
• Maintain a UM application that ensures consistent workflow and a comprehensive database of UM activity that allows for tracking of programmatic status, compliance, timeliness, accuracy, and cost-avoidance.
• Establish and monitor progress towards goals for UM programs, including days out, turnaround times, timeliness, and quality of reviews, training, and physician outreach efforts.
• Oversee processes and application to ensure the protection of personal health information.
• Ensure Clinicians are providing timely notification of large cases to finance, underwriting, stop loss and other company leaders, as necessary.
• Facilitate the provision of exceptional service to members, providers, employers, agents, and other external and internal customers, ensuring that service meets company and customer expectations.
• Serve as clinical resource to other departments, including but not limited to : underwriting, claims, pharmacy, finance, quality improvement and sales.
• Serve as a UM resource regarding policies, procedures, and operations.
• In regional offices, represent UM on management teams, as requested, and support marketing and development initiatives towards achievement of PacificSource Health Plans goals specific to the region.
• Attend continuing education events to ensure that PacificSource UM programs maintain current industry best practices.
• Foster effective teamwork and performance.
• Manage change and encourage innovation, build collaborative relationships, encourage involvement, initiative, and goal orientation in others.
• Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees.
• Provide feedback, including regular one-on-ones and performance evaluations, for direct reports.
• Develop annual department budget.
• Monitor spending versus the approved budget throughout the year and take corrective action where needed.
• Responsible for process improvement and collaboration with other departments to improve interdepartmental processes.
• Utilize Lean methodologies for continuous improvement.
• Utilize visual boards and facilitate daily huddles to monitor key performance indicators and identify improvement opportunities.
• Actively participate as a key team member in Manager / Supervisor meetings.
• Actively participate in various strategic internal and external committees to disseminate information and represent company philosophy.

Supporting Responsibilities :

Work Experience :

7 years clinical experience required and a minimum of 3 years direct health plan experience in case management, utilization management, or disease management. Prior supervisory or management experience required.

Education, Certificates, Licenses :

Registered Nurse or Licensed Clinical Social Worker with current appropriate state licenses. Certified Case Manager Certification as accredited by CCMC preferred.

Knowledge :

Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, procedure codes, including ICD-9 & 10, CPT codes, health insurance and State of Oregon mandated benefits. Knowledge of managed care products and third party liability (TPL) is required. Ability to develop, review and evaluate utilization and case management reports. Knowledge of health insurance and State mandated benefits experience in adult education preferred.

Competencies : Building Trust

Building a Successful Team

Aligning Performance for Success

Building Partnerships

Customer Focus

Continuous Improvement

Decision Making

Facilitating Change

Leveraging Diversity

Driving for Results

Environment :

Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.

Skills :

Accountable leadership, Collaboration, Communication, Data-driven & Analytical, Delegation, Listening (active), Situational Leadership, Strategic Thinking

Our Values :

We are committed to doing the right thing. We are one team working toward a common goal. We are each responsible for customer service. We practice open communication at all levels of the company to foster individual, team and company growth. We actively participate in efforts to improve our many communities-internally and externally. We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community. We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements :

Stoop and bend. Sit and / or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer : This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.