RN - Manager of Utilization Management - WellMed - San Antonio, TX

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work.(sm)
 
The Manager of Utilization Management Operations is responsible for driving cost effective, quality of care services for members through daily coordination among medical directors, UM staff, the provider network and various other departments. This position is also responsible for overseeing all compliance functions, the denial and appeal process and for providing administrative and leadership support to staff in accordance with policies and procedures.
 
Primary Responsibilities:

Performs daily oversight for the UM Supervisors
Manages the compliance for UM phone queue to meet established performance metrics
Oversees medical claim review inventory and regulatory timeframes
Manages all aspects of the UM claim review inventory and service timeframes.
Manages all aspects of the Inpatient Census and CM support inventory and service timeframes
Manages all aspects of the denial and UM correspondence inventory and service timeframes
Conducts routine audits on UM reviews to ensure adherence to CMS regulations
Produces daily, weekly and monthly operational reports for senior leaders
Organizes and presents at staff meetings and provider education sessions on utilization management processes
Applies employee performance management techniques through job-related coaching, training and development activities
Performs all other related duties as assigned

Required Qualifications:

Associate’s degree in healthcare administration, business administration or related field required. (4 additional years of comparable work experience beyond the required years of experience may be substituted in lieu of a associate’s degree.)
Current Nursing Licensure or Current RN Licensure (unrestricted license)
3 years of related experience with at least 2 years in a supervisory capacity
Related experience in prior authorization or claims review
Medical terminology, ICD-9/ICD-10 and CPT knowledge
Proficiency with Microsoft Office applications
Preferred Qualifications:

More than 5 years of managed care experience in prior authorization or claims review
Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 90,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
 
Job Keywords: RN, registered nurse, utilization management, UM, UR, utilization review, prior authorization, manager, supervisor, charge nurse, team lead, WellMed, UnitedHealth Group, UHG, UnitedHealthcare, UHC, Texas, TX, San Antonio