Maintains accountability for medical management functions to achieve the business and clinical outcomes for the health plan, meeting contract requirements, National Committee of Quality Assurance (NCQA) accreditation standards, and supporting initiatives with providers and members to manage cost of care. Oversees utilization management and criteria-based reviews of care, clinical appeals regarding medical necessity, and the interaction with claims payment policies and processes. Also oversees the health plans 24/7 Nurse Line program and the clinical management of crisis calls.
Directs, coordinates and evaluates efficiency and productivity of utilization management functions.. Works closely with pharmacy and vendors to assure integration, oversight, and efficiency of utilization management and appeals processes and for delegated functions. In collaboration with the national clinical team, assures that all utilization management-related activities meet the standards required for the state contract and NCQA.
Leads and organizes the ongoing evaluation of the utilization management program against quality and utilization benchmarks and targets. Identifies opportunities for improvement; organizes and manages cost of care initiatives. Collaborates with local and national leaders including Quality Improvement, Analytics, Finance, Network, and other areas to assure a comprehensive approach to managing quality of care, service, and cost of care. Provides expert input to Finance regarding patterns of utilization and cost and high cost cases.
Assures staff selection, training, and evaluation to promote the development of a high quality team and effective transitions of care with the clinical care teams.
Works closely with and provides input to national health plan clinical team on program design, policies, procedures, workflows, and correspondence.
Collaborates with Network leaders to design and implement successful methods for working with hospitals, home health, and other services providers. Ensures integration and efficiency of Network strategy and vendor relationships with utilization management and claims processes. Works closely with network on the training and evaluation of providers as well in resolving provider related issues.
Directs staff who assure quality, inter-rater reliability and standards are met in daily operations. Responsible for resolution and communication of utilization management issues and concerns and corrective action plan activities and reporting.
Participate as a member of health plan Quality Insurance Committee and co-chair health plan Utilization Management Committee.
Bachelors: Nursing (Required), Masters: Behavioral Health (Required)
License and Certifications - Required
BCBA - Board Certified Behavior Analyst - Care Mgmt, LCMFT - Licensed Clinical Marriage and Family Therapist - Care Mgmt, LCSW - Licensed Clinical Social Worker - Care Mgmt, LMHP - Licensed Mental Health Professional - Care Mgmt, LPC - Licensed Professional Counselor - Care Mgmt, RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt
License and Certifications - Preferred
Other Job Requirements
Licensure is required for this position, specifically a current license that meets State, Commonwealth or customer-specific requirements. One or more of the following current, active licenses are required: LCMFT, LCSW, LMHP, LPC or RN. If hired to support the Autism line of business, must be a Board Certified Behavioral Analyst (BCBA). Behavioral Analysis is the area of specialization in autism care.
Experience with reporting and analyzing managed care utilization data.
Strong verbal and written communication skills.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.