Sr. Manager-Utilization Management (RN) - Community Health Choice
Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 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.
• Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
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.
Skills / Requirements
Responsible for managing clinical and nonclinical team members. 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. Complete deliverables within established time lines. Responsible to ensure the auditing of staff monthly, and as needed to maintain compliance with state, federal and accreditation requirements. Facilitates clinical rounds and recommends training as needed. Ensures that organizational and departmental goals, as identified in Department's annual Business Plan, including specific departmental process improvement plans are met. Serves as the subject matter expert for assigned line of business. Acts 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. Responsible for staff development and performance management. Trouble shoots and investigates authorization issues as needed. Manages the staffing needs by reviewing analytic reports for productivity, pended cases, and average admissions per facility etc. Participates in workgroups across the organization and makes recommendations for improvement. Complete deliverables within established time lines. Actively fosters and engage in efforts to ensure a culture of collaboration and teamwork within Community's Leadership as well as with all internal and external partners. Supports organizational goals as outlined in the program description. Demonstrates Harris Health and Community Health Choice values, including trust, integrity, mutual respect, diversity, responsiveness and caring service. Complete other duties as assigned by the Director of Utilization Management and SVP Medical Affairs.
1. Education/Specialized Training/Licensure:
RN required, Bachelors degree in Nursing (BSN) preferred. Current, unrestricted license in the state of Texas, Master of Business Administration (MBA), Master of Health Administration (MHA) and/or Master of Science in Nursing (MSN) preferred. Experience in Medicaid and/or Commercial lines of business
2. Work Experience:
Understand the Utilization Review process including census management
Experienced with medical necessity guidelines including MCG guidelines and/or Interqual guidelines
3-5 years of managed care experience
3. Management Experience :
3-5 years of supervisory or leadership experience.
4. Equipment Operated: Moderate level of computer knowledge with word, excel, outlook , PowerPoint and access data bases.
1. Communication Skills:
Above Average Verbal (Heavy Public Contact)
Exceptional Verbal (e.g., Public Speaking)
Bilingual Skills Required No
Writing /Composing Correspondence / Reports
2. Other Skills:
Analytical Medical Terms
P.C. MS Word MS Excel
3. Advanced Education:
Advance Training Specialty: CCM preferred
Bachelor¿s Degree Major: BSN preferred.
4. Work Schedule: Flexible
5. Other Requirements: Ability to work autonomously, self-motivated, critical thinker, solution oriented, ability to perform at a high level under pressure and short deadlines.
RESPONSIBLE TO: Director Utilization Management
EMPLOYEES SUPERVISED: Clerical Service