The primary purpose of this position is to manage Innovations waiver I/DD Service Authorization and Care Management system and the utilization management and Utilization Review functions. Provides direct supervision to UM I/DD Care Managers. Plans, directs, coordinates and evaluates the overall clinical practice and administrative activities of the utilization management/care management staff, including personnel management. Participates in the development of and implementation of policies and procedures. Maintains open communication with all staff to promote improvement in performance. This position requires a sound knowledge of clinical practice and exceptional leadership abilities. The I/DD UM Supervisor may represent the unit in cross agency collaborative needs.
Responsibilities and Duties
Provides supervision within the Utilization Management Department that has a focus on timeliness, effectiveness, quantity, quality, and cost of services for eligible enrollees.
Complete mediations for denial or reduction of Innovations Waiver services.
Represent Utilization Management determinations for Innovations Waiver and ICF services in court as requested by legal counsel.
Review and Revise unit Desk Manual as needed.
Coordinate and integrate services within the department and with other departments.
In conjunction with the Director of Utilization Management, develop and implement department policies and procedures that guide and support the utilization of services.
Assess and improve the department’s performance based on established indicators and outcomes.
Develop and maintain open timely communication with staff, providers, community agencies and other stakeholders.
Attend federal, state and local meetings as agency liaison.
Ensure authorized services address appropriate service needs, intensity of service outcomes, and alternatives for consumers.
Ensure staff compliance with the Medical Necessity Criteria policy used to determine appropriate level and type of care for eligibility and service.
Ensure staff compliance with Due Process requirements for Innovations Waiver and ICF services.
In conjunction with the Director of Utilization Management, define and monitor staff productivity standards.
Ensure UM Care Managers provide ongoing care management to individuals in intensive levels of service.
Refine and reevaluate the methods of authorization for services and treatment.
Hold IDD UM Care Manager staff accountable for documenting assessment of client diagnosis, development and monitoring of Service or Treatment plans as appropriate for service authorization.
Hold staff accountable for reviewing ongoing care to affect individual client outcomes.
Ensure UM staff monitor service plans for coordinated treatment between I/DD, behavioral and medical providers as indicated.
Ensure the unit focuses on compliance with clinical guidelines, treatment effectiveness, appropriate allocation of resources, and identifying undetected risk.
Set standards for systematic reviews for conformity and take corrective action as necessary to enforce strong clinical practices.
Monitor compliance with the MCOs contract requirements with DMH and DMA.
Monitor compliance with URAC/HUM, NCQA standards.
Provide technical assistance to providers as needed.
Ensure UM I/DD staff maintain proper documentation.
Recruit, hire and train staff for satisfactory performance; enforce disciplinary action when necessary.
Requirements
Master's Degree in a human services field and three years of professional developmental disabilities experience including one year of developmental disabilities supervisory experience; or graduation from a four-year college or university with a degree in a human services field with four years of professional developmental disabilities experience including one year of developmentally disabilities supervisory experience. A minimum of two years of Utilization review experience required.
Knowledge and Skills
Technical knowledge of general authorization principles and standard, working knowledge of State guidelines and policy related to utilization management and review.
Considerable knowledge of populations being served.
In depth knowledge of the Innovations Waiver.
Ability to use SIS evaluations in the determination of appropriate levels of care.
The ability to retrieve, communicate and present data and information both verbally and in writing required; as is the ability to express or exchange ideas verbally and in writing.
Must employ a professional style that promotes interagency cooperation and have the ability to promote efficient use of program resources to attain desired outcomes.
Possess excellent problem solving skills.
Must be creative, highly motivated and able to operate successfully within a team management model.
Must have through knowledge of Diagnostic Treatment Guidelines/Protocols, Supports Needs Matrix, Authorization/Re-authorization Standards, and Utilization Management Standards.
Salary Range
$56,132 - $96,630/Annually
Licenses & Certifications
Required
Driver License
Skills
Required
Analysis
Communication
Coordination
Customer Service
Behaviors
Required
Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well
Preferred
Team Player: Works well as a member of a group
Leader: Inspires teammates to follow them
Innovative: Consistently introduces new ideas and demonstrates original thinking
Motivations
Preferred
Goal Completion: Inspired to perform well by the completion of tasks
Ability to Make an Impact: Inspired to perform well by the ability to contribute to the success of a project or the organization
