Job Description:

Summary:

This position is responsible for managing escalated and complex case management reviews, utilization management reviews and audits for the applicable line of business. The position acts as the primary point of contact for the Clinical Operations department and assists in providing direction to staff for the day-to-day activities of the functional areas, including assessment of daily workload for distribution, problem resolution, crisis intervention, functional clinical and technical expertise, and performing clinical review, as needed.

Essential Primary Responsibilities/Accountabilities:

• Coordinates the daily activities of the clinical operations staff.


• Evaluates day-to-day workload and processes to maximize productivity and efficiency and staff satisfaction.


• Works with assigned management to ensure that regulatory, compliance and accreditation standards are being met.


• Functions as a resource to the CM staff or UM staff, members and providers and takes the lead on issues that need immediate assistance.


• Functions as a clinical reviewer for (CM) case management or utilization management (UM) functions and assists with day-to-day work, as needed.


• Identifies and recommends the development of clinically appropriate, cost effective programs to meet member, provider and corporate needs.


• Identifies and recommends the development of process improvements, as necessary.


• Collaborates in a matrix fashion with internal departments and external regulators to maintain compliance with all regulatory requirements and accrediting standards. Keeps abreast of changes and responsible for implementation and monitoring of requirements.


• Creates and/or maintains updated departmental policies, procedures and desk level procedures relative to the functions in collaboration with assigned management and training staff.


• Performs periodic quality audits of staff performance to ensure staff meets/exceeds departmental/corporate requirements in collaboration with management. Develops corrective action plans, training material and perform training as needed.


• Maintains staff and departmental quality and volume related statistics and provides documentation to departmental management.


• Organizes the orientation and continuing education/training for staff as necessary.


• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct and leading to the Lifetime Way values and beliefs.


• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.


• Regular and reliable attendance is expected and required.


• Performs other functions as assigned by management.

Minimum Qualifications:

• Registered Nurse with current NYS license, Bachelors degree preferred.


• OR: New York State Licensed Clinical Social Worker (LCSW)


• OR: New York State Credentialed Alcoholism and Substance Abuse Counselor (CASAC).


• Minimum of three years clinical experience in above licensed profession required.


• Minimum of one year of recent Utilization Management and/or Case Management experience


• Experience in interpreting health plan benefit plans and strong knowledge of contracts & benefits preferred.


• Knowledge of NCQA, InterQual criteria and/or Medicare and Medicaid guidelines preferred.


• Demonstrated ability to multitask and balance priorities.


• Demonstrated leadership skills with the ability to problem solve and effectively communicate.


• Ability to work independently.


• Must demonstrate proficient experience in the Microsoft Office Suite, including Word, Outlook, Excel, PowerPoint and internet browsers


• Excellent written and verbal communication skills and organization skills are required.

Physical Requirements:

• Works from a desk most of the workday.

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The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.

Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.

OUR COMPANY CULTURE:

Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s):

Grade 207: Minimum $60,070 - Maximum $111,114

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position's minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note: The opportunity for remote work may be possible for all jobs posted by the Univera Healthcare Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.