Duties//Responsibilities:
Provide strategic oversight and operational management for all utilization management functions, including prior authorization, concurrent review, and service requests
Lead, coach, and develop UM managers overseeing interdisciplinary teams of registered nurses, social workers, clinicians, and coordinators
Ensure UM operations meet regulatory requirements set forth by CMS, New York State Department of Health (DOH), and other oversight entities
Establish, monitor, and report on key performance indicators (KPIs), productivity, and quality metrics to ensure compliance and optimal performance
Partner with Clinical Operations, Quality, Compliance, and Provider Relations to ensure alignment and effective communication across departments
Utilize data analytics and reporting tools to identify trends, drive process improvements, and optimize resource allocation
Lead readiness efforts for audits, performance improvement plans, and corrective actions related to utilization management
Foster a culture of accountability, professional development, and continuous improvement across all levels of the team
Serve as a subject matter expert and escalation point for complex or high-impact cases requiring clinical and operational judgment
Support system implementations and technology enhancements to improve automation, reporting, and member//provider experience
Ensure the department maintains timely and accurate completion of service authorizations and reviews in alignment with turnaround time standards
Additional duties as assigned
MinimumQualifications:
Bachelors degree in Nursing, Healthcare Administration, or a related field from an accredited institution or equivalent work experience
NYS RN
Demonstrated understanding of UM regulatory requirements, clinical review process, and managed care operations
Leadership experience in managing, coaching and developing multidisciplinary clinical teams
Strong analytical, organizational, and problem-solving skills
Work experience demonstrating written and verbal communication skills with the ability to influence and collaborate across functions
Demonstrated success driving high performance and quality outcomes in a fast-paced, regulated environment
Preferred Qualifications:
Prior experience leading a team of people leaders
Work experience using Milliman Care Guidelines (MCG) criteria and other state-specific authorization requirements.
Ability to interpret and operationalize regulatory updates and guidance from DOH and CMS
Experience working and//or managing in a virtual environment
Understanding of health plans such as Medicare, Medicaid and//or Managed Long-Term Care Plan (MLTCP)
Experience working as a case manager for a long-term care programs such as PACE, MAP or MLTC
Strong understanding of value-based care principles and their application to MLTC populations
Experience accessing and maintaining patient health information (PHI) electronically in a shared network
Strong computer skills, including, but not limited to word processing, spreadsheets, and databases
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.