Sr. Manager, Utilization Management - 154842
Community Health Choice, Inc. (Community) is a non-profit Health Maintenance Organization (HMO) licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 70 hospitals, Community serves over 260,000 Members with the following programs:
• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
• Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
• Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
The Sr. Manager, Utilization Management is responsible for managing clinical and nonclinical team members and may oversee complex case management, concurrent review, prior authorization, call center and or letter teams. Identifies, implements, and evaluates relevant performance metrics that allow for objective evaluation of staff and/or departmental performance. Responsible for monitoring and facilitating the attainment of performance metrics to meet departmental expectations for productivity and quality. Responsible for managing staffing requirements for daily workload and auditing of letters to comply with all regulatory requirements. Responsible to ensure the auditing of staff monthly, and as needed to maintain compliance with state, federal and accreditation requirements. Other responsibiilites include:
- Facilitating clinical rounds and recommends training
- Ensuring that organizational and departmental goals, as identified in department's annual business plan, including specific departmental process improvement plans are met.
- Serving as the subject matter expert for assigned line of business.
- Acting as a department liaison/project manager on initiatives where collaboration is required for departmental and organizational goal attainment. In collaboration with the UM trainer (s) is responsible for staff onboarding.
- Providing for staff development and performance management. Trouble shoots and investigates authorization issues as needed.
- Managing the staffing needs by reviewing analytic reports for productivity, pended cases, and average admissions per facility etc.
- Participating in workgroups across the organization and makes recommendations for improvement.
- Fostering and engaging in efforts to ensure a culture of collaboration and teamwork within Community's Leadership as well as with all internal and external partners.
- BSN degree, active Texas RN license.
- Certifications in Managed Care, or Utilization Management required or must receive within 18 months of employment.
- Master of Business Administration (MBA), Master of Public Health (MPH), Master of Health Administration (MHA) and/or Master of Science in Nursing (MSN) preferred.
- Three years’ experience in Utilization Management in a Management Care environment required.
- Five years supervisory experience of Managers or above required.
- Experience with working with applicable state, federal and third party regulatory agencies such as, CMS, HHSC, TDI, Medicaid or Medicare programs required.
Benefits and EEOC
Community employees’ benefits are provided by Harris Health. These benefits are designed to provide you with flexibility and choices in meeting your specific needs.
Community is an Equal Opportunity Employer.