Job Information

Excellus Health Plan Inc. Supervisor, Utilization Management (Commercial) - 014250 in Plattsburgh, New York

Summary: This position supervises, coordinates and is accountable for the daily work of employees who provide utilization management, clinical and medical necessity claim related services and support. This position facilitates day-to-day operations of the department such as prospective, concurrent and retrospective customer requests, claim queues and coordination of department workflow, projects, staffing, etc. The Supervisor provides Medical Services representation at various internal and external meetings. Essential Responsibilities/Accountabilities: - Provides direction and supervision to the assigned Medical Services staff including departmental function, individual development plans, performance reviews, and disciplinary actions. Also, provides supervisory services to assigned personnel - such services include, but are not limited to, selection, placement, training, and counseling, enforcing rules and regulations, monitoring attendance and punctuality and recommendations relative to changes in status. Responsible for coordinating communications and daily activities of the staff and assuring adequate staffing to accomplish corporate goals.- Assesses daily, weekly and monthly volumes of work and adjusts assignments as needed. Monitors staff's productivity related to set productivity metrics continually and addressing performance issues as they arise...- Coordinates communication between Medical Services and providers.- Participates in recruitment, training, and retention of staff.- Assists in the development of Desk Level Procedures (DLPs), policies and procedures related to Medical Services.- Acts as liaison with other departments, members, providers and all customers.- Assists in implementing and monitoring departmental changes and initiatives necessary to accomplish corporate goals.- Coordinates and facilitates regular team meetings with staff.- Applies project management skills by developing and implementing new initiatives.- Provides presentations as relates to specific functions of area supervised.- Understands premium protection initiatives & adjusting resources/functions as needed to reach goals.- Meets with facilities and providers to set up communications/referral links and negotiations. Contributes pertinent information to contracting negotiations.- Identifies strategies to improve health care resource management and communicates to internal and external customers.- Instructs and acts as a resource for staff in dealing with special situations or problems.- Maintains documentation relative to the activities of the department and prepares reports as necessary. Keeps designated management aware of progress toward goals and productivity.- Conducts periodic performance reviews for direct reports, identifying areas needing improvement and initiates appropriate action including productivity monitoring and inter-rater reliability.- Maintains compliance with all regulatory and accrediting standards. Keeps abreast of changes and responsible for implementation and monitoring of requirements.- Provides supervisory services to assigned personnel for the Corporate Affirmative Action Program. Such services include, but not limited to, selection, placement, training, performance appraisal, and counseling, enforcing rules and regulations, application of approved discipline, monitoring attendance and punctuality and recommendations relative to changes in status.- 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.- Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements.- Conducts periodic staff meetings to include timely distribution and education related to departmental and Ethics/Compliance information.- Regular and reliable attendance is expected and required.- Performs other duties and functions as assigned by management. Minimum Qualifications: - Current New York State clinical licensure (RN or a Licensed Behavioral Health Clinician) with a minimum of three years of utilization management/quality improvement experience or equivalent- Must possess a thorough understanding of the corporation and provider community- Experience in interpreting health plan benefit plans- Basic knowledge of InterQual criteria, Corporate Medical Policies, and/or Medicare and Medicaid guidelines preferred- Basic familiarity with Managed Care legislation, NCQA, and Federal and State regulatory requirements- Must possess excellent written and verbal communication skills, problem solving and analytical skills and the ability to deal effectively with all levels of personnel in the health care industry- Must possess strong LTW behaviors and strong LTW cultural attributes. Physical Requirements: - Must be able to travel independently between the health plan regions. ************ 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 Equal Opportunity Employer - minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity