• Manage activities of the medical and behavioral health services programs that includes Utilization Management which is comprised of Prior Authorization, Concurrent Review, Case Management
• Supervise assigned Health Services Department staff
• Develop and implement strategic clinical programs that will focus on transforming the current health services department functions and workflows with the goal of improving patient safety and healthcare, advancing proactive health initiatives, and maximizing operational efficiency
• Develop departmental policies and procedures, job aids and training materials
• Work with vendors as needed to develop and implement utilization management initiatives that will improve the authorization review process
• Have a working knowledge of NCQA and TDI requirements as it applies to Prior Authorization, Concurrent Review, Appeals and Case Management including turn-around-times associated with clinical review processes
• Be well versed in the application of InterQual clinical criteria as it pertains to the clinical review process
• Coordinate the daily operations with the Health Services Director and other leadership staff in the Health Services department, monitor staff performance, and at times may conduct, utilization review activities and coordination/assistance with the management of member's medical, behavioral and pharmaceutical care and services through Discharge Planning and referrals to General and Complex Case Management and Disease Management Programs
• Work with a wide range of people including health plan staff, members, physicians, hospitals, vendors and other providers
• Have frequent or daily access to confidential information and protected health information
• Handle other duties as assigned by the Health Services Director
Develops, implements and manages programs that provide effective and efficient medical and behavioral health services to clients including utilization management, general/complex and disease management programs, ensures compliance with all applicable state and federal regulatory requirements and oversees operational policy and procedure development.
• Provides leadership in the analysis of medical care and pharmaceutical cost and utilization management activities to optimize program effectiveness and manage the development of techniques to effectively correct identified and anticipated utilization and other case/disease management needs.
• Assists the Health Services Director with managing the operational and fiscal activities of the unit which includes staffing levels, budgets, financial and operating goals and plans, and develops systems and procedures to improve the quality and efficiency of operations in order to meet productivity and quality goals.
• Hires and supervises staff in accordance with personnel policies and procedures including orientation and training, providing career development advice, establish employee goals, conducting performance reviews, coaching, counseling and disciplining staff, and recommending terminations if needed.
• Assists in the day to day operations of the department to include assisting/directing Program Specialists, Prior Authorization Nurses (RNs), Concurrent Review Nurses (RNs), RN Case Managers, Medical Social Workers, and Community Health Workers (CHWs). Provides staff support and direction with individualized assistance to members experiencing complex, acute/chronic medical or behavioral illnesses, conditions or catastrophic injuries that may benefit from a case management support program as outlined in the policies and procedures.
• Collaborates with Sendero's Pharmacy Benefit Management (PBM) team, Medical Director and Health Services Director with reviewing and analyzing drug utilization reports
• Strong knowledge of Managed Care principles and practices, involving medical and behavioral, General, Complex and Disease Case Management, Utilization Management to include Inpatient and Outpatient Prior Authorizations, Concurrent Review, Discharge Planning, Appeals, Pharmaceutical Management and NCQA.
• Strong administrative management skills involving business and organizational planning, coordination, and execution including resource allocation, leadership techniques and production methods, short and long-term budgeting and forecasting.
• Strong clinical knowledge and experience in the treatment of human injuries, diseases, and deformities including symptoms, treatment alternatives, drug properties and interactions, behavioral health conditions, preventive health guidelines and InterQual Criteria.
• Ability to manage workload; work efficiently and effectively in performing the duties of the position and within established policies and procedures.
• Excellent interpersonal skills with ability to interface and motivate effectively internally and externally with a wide range of people including members, parents, providers, and health plan staff
• Strong verbal, listening, presentation and written communication skills
• Significant experience in analysis of data including quantitative and barriers analysis of data, identify interventions, implementing interventions, and evaluating the effectiveness of these interventions.
• Ability to provide guidance and direction to staff in the performance of their duties.
• Flexibility and competency to handle multiple and different responsibilities on any given day.
• Ability to utilize a personal computer and commonly used software such as word, excel, access and to understand and become proficient in the use of medical management software post training.
People Management/Department Management/Business Unit :
• Familiarity with Sendero’s policies and procedures, TDI/HHSC/NCQA/Medicaid/Marketplace guidelines
• Ability to learn a variety of job descriptions
• Outstanding organizational & leadership skills
• Excellent knowledge of MS Office
• Participates in interdepartmental integration and collaboration to enhance the continuity of care for members including Behavioral Health.
• Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.
• May assist in the research and resolution of claims payment issues.
• Develops, implements, monitors, and evaluates UM and case management processes and programs to include STAR, CHIP, CHIP Perinate, and Commercial/Health Exchange programs.
• Provides constructive information to minimize problems and increase customer satisfaction.
• Assists the Health Services Director with managing the operational and fiscal activities of the unit which includes staffing levels, budgets, financial and operating goals and plans.
• Develops the UM and Case Management programs in accordance with NCQA, HHSC, TDI and other regulatory agency requirements to assure overall compliance with all standards.
• Interviews, hires, educates, and trains staff in accordance with personnel policies and procedures to create and maintain high performance teams.
• Conducts performance evaluations, provides individual coaching, and develops disciplinary action improvement plans when needed to maintain operational effectiveness.
• Promotes staff development to support professional growth.
• Mentors and serves as an operational and clinical resource.
• Conducts quality chart audits to ensure compliance of regulatory standards.
• Tracks and trends outcomes and analyzes data to identify improvement opportunities and maintain quality standards.
• Other duties as assigned
MINIMUM EDUCATION: RN Degree from an accredited School of Nursing (BSN, ADN, Diploma
PREFERRED EDUCATION: Bachelor’s Degree
MINIMUM EXPERIENCE: 5 years of experience in Medicaid/Marketplace managed care setting
PREFERRED EXPERIENCE: 5 years of leadership experience in quality improvement, utilization management, disease management and/or case management in a managed care setting.
REQUIRED CERTIFICATIONS/LICENSURE: TX Registered Nurse License