Primary Function
Responsible for the development, implementation, and management of the following programs:

• Utilization Management (Including prior authorization, DME, Home Health, Referral Management and admissions to acute hospital, long term acute care facility, acute rehab and skilled nursing admissions).
• Case Management (Management of members with chronic conditions and episodic case management for all other members through rapid response unit).
• Member education
• Solutions management
 Provide direct supervision for the daily operations of the Utilization, Referral and Chronic Care Managers and Solutions Unit Supervisor. Work with the Medical Director in overseeing medical policies, medical service delivery and quality of care for health plan members. Support provision of high quality, cost-effective clinical care in efficacious relationships with health care providers. Manage health plan risk effectively. Support maintenance of marketable, high quality, cost effective provider network. Provide effective human resources management.

Responsibilities

• Responsible for the development and management of business plans and budgets for the Health Services Department.
• Responsible for making recommended changes and enhancements to services and benefits.
• Implements management processes according to organization and department policies and procedures.
• Collaborates with Network Management to enhance relationships with Network facilities, to remove barriers to service and care for members and to communicate health plan policies and procedures.
• Develops and implements strategic plan to achieve organizational goals and objectives including ADK (Admissions per 1000) and MCR (Medical Cost Ratio).
• Conducts interviewing, hiring, coaching and counseling in conjunction with HR policies and procedures.
• Establishes a working knowledge of information business systems utilized to administer health services programs, reimburse network facilities and providers and to gather and report outcome data.
• Conducts analysis of inpatient, outpatient and clinical data to identify utilization trends and to implement appropriate corrective action plans.
• Support and participate in physician, hospital, and ancillary provider education.
• Actively participate in corporate meetings such as Medical Management Round Table, HSA Committee and other operational meetings to identify and resolve barriers, outline health services strategy, to share best practices and to implement required operational changes.
• Responsible for oversight of the administration of grievance, appeal, and provider dispute functions.
• Demonstrates effective listening skills and makes recommendations for change based on observations.
• Develops and administers department budget and staffing.
• Creates and maintains internal and external customer focus.
• Responsible for compliance with all regulatory and accreditation standards.
• Maintains staff morale and promotes organizational values.
• Work with managers in addressing performance issues in a timely and sensitive manner.
• Assists the Medical Director in tasks as assigned.

Supervisory Responsibilities
Hire, manage, and evaluate management personnel. Travels to other sites to perform interviews.

Job Related Skills
• Advanced leadership and personnel management skills.
• Broad knowledge of managed care concepts.
• Excellent analytical, organizational and decision making skills.
• Strong communication skills.
• Excellent written, verbal, and customer service skills required.

Experience
• Current Mississippi license, RN required.
• Bachelors degree.
• 10 years experience in utilization/quality management.
• Five years experience in management and clinical.