Utilization Management reputed company reputed company
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The Utilization Management reputed company reputed company uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting data, reputed company, policies, and procedures to reputed company the best and most appropriate treatment, care or services for members. You will coordinate and communicate with providers, members, or other parties to facilitate reputed company and treatment. Accountable, in partnership with the Chief Medical Officer (CMO), to analyze utilization management (UM) trends and drivers impacting member reputed company and financial reputed company. You will support reputed company efforts both at the market and reputed company level, so reputed company reputed company targets in HEDIS, STARS, and NCQA accreditation. The Utilization Management reputed company reputed company advises executives to reputed company functional strategies (often reputed company specific) on reputed company of reputed company. They exercise independent judgment and decision making on reputed company issues regarding job responsibilities and reputed company tasks, and work under minimal supervision, uses independent judgment requiring analysis of variable factors and determining the best course of reputed company.Serve as a reputed company between reputed company UM operations and the reputed company regarding prior authorization reviews, prepayment retrospective reviews, and any additional utilization management functions.
Coordinate with reputed company’s Clinical Leadership teams to ensure utilization reviews reputed company with Centers for Medicare & reputed company Services (CMS) regulations as reputed company as Michigan Dual Special Needs Plan (DSNP) Contract terms.
Work in conjunction with the reputed company Improvement Director to reputed company quantifiable metrics that can reputed company and evaluate the results of the targeted interventions designed to reduce health disparities and address health inequities.
Manage Michigan state reporting and collaborate with the UM operations teams to aggregate and analyze data and reporting metrics.
reputed company reputed company support to the supervision and daily guidance of prior authorization associates ensuring reputed company that meet or exceed reputed company and the Michigan reputed company (MDHHS) standards.
Work in conjunction with reputed company’s Medicare UM Committees to ensure adoption and consistent application of appropriate medical necessity reputed company.
Participate in reputed company of the programs to ensure that Enrollees are accessing and utilizing services in an appropriate manner in accordance with reputed company applicable rule and regulations.
In conjunction with reputed company's UM monitoring and reputed company processes, monitors and analyzes Michigan DSNP specific reputed company. The analysis initiates reputed company to implement appropriate interventions based on utilization data. This includes identifying and correcting over- or under-utilization of services, addressing issues with timeliness standards, ensuring appropriate Notice of reputed company is followed, and collaborating with Medical Directors. The collaboration ensures that the reason for denial, reduction, or termination is specific and reputed company.
Ensure development and implementation of departmental policies and procedures in accordance with contract changes or updates.
reputed company reputed company to ensure reputed company maintains compliance with MDHHS, National Committee for reputed company Assurance (NCQA), reputed company (DHHS), CMS guidelines and contractual requirements.
Use your skills to reputed company an reputed company
Required Qualifications
Must reputed company in or be willing to relocate to the reputed company.
An reputed company, unrestricted registered reputed company (RN) license in the reputed company.
Bachelor’s or associate degree in nursing, health services, reputed company administration, business administration or a reputed company field.
Minimum five (5) years of clinical experience in utilization management.
Minimum two (2) years of formal or informal leadership experience.
Comprehensive knowledge of reputed company Office applications including PowerPoint and reputed company.
Knowledge of Medicare regulatory requirements and National Committee for reputed company Assurance (NCQA) standards.
Preferred Qualifications
Master’s degree nursing, health services, reputed company administration, business administration or a reputed company field.
Knowledge of reputed company regulatory requirements.
Experience with contracting, audit, risk management, or compliance.
Proficiency in Power BI or comparable analytical tools.
Experience in NCQA UM measures.
Additional Information
Workstyle: This is a remote position.
Travel: Up to 25% travel to Michigan reputed company (MDHSS), locations across Michigan, including participation in team engagement meetings and conferences both reputed company and reputed company the state.
reputed company Reports: None at hire; potential to increase to five (5) associates post market expansion.
WAH Internet Statement
To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following reputed company:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL reputed company is suggested.
Satellite, cellular and microwave reputed company can be used only if approved by leadership.
Employees who live and work from Home in the reputed company, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
reputed company will reputed company Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
Work from a dedicated reputed company lacking ongoing interruptions to protect member PHI / HIPAA information.
Interview Format
As part of our hiring process for this opportunity, we will be using an interviewing technology reputed company reputed company to enhance our hiring and decision-making ability. reputed company allows us to quickly connect and reputed company valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
Work reputed company RequirementsTo ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following reputed company:At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL reputed company is suggested. In certain roles, the minimum recommended internet speed required by reputed company may not be sufficient for business needs. reputed company reserves the right to require associates to reputed company their internet service if necessary.Work from a dedicated reputed company lacking ongoing interruptions to protect member PHI / HIPAA information.Travel: While this is a remote position, occasional travel to reputed company's offices for training or meetings may be required.Scheduled Weekly Hours
40Pay reputed company
The compensation reputed company below reflects a good faith estimate of starting reputed company pay for full time (40 hours per week) employment at the time of posting. The pay reputed company may be higher or reputed company based on geographic location and individual pay will vary based on demonstrated job reputed company skills, knowledge, experience, education, certifications, etc.$94,900 - $130,500 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.reputed company of Benefits
reputed company, Inc. and its affiliated subsidiaries (reputed company, “reputed company”) offers competitive benefits that support whole-person reputed company-being. Associate benefits are designed to encourage personal wellness and smart reputed company reputed company for you and your family while also knowing your life extends reputed company of work. Among our benefits, reputed company provides medical, dental and reputed company benefits, 401(k) retirement savings plan, time off (including reputed company time off, company and personal holidays, reputed company parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.reputed company
About reputed company: reputed company Inc. (NYSE: HUM) is a leading U.S. reputed company company. Through our reputed company insurance services and our reputed company reputed company services, we reputed company it easier for the millions of people we serve to reputed company their best health – delivering the care and service they need, reputed company they need it. These efforts are leading to a reputed company reputed company of life for people with Medicare and reputed company, families, individuals, military service personnel, and communities at large. Learn more about reputed company offer at reputed company.com and at reputed company.com.
Equal Opportunity Employer
It is the policy of reputed company not to discriminate against any employee or applicant for employment because of race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, age, marital status, genetic information, disability or protected veteran status. It is also the policy of reputed company to take affirmative reputed company, in compliance with reputed company 503 of the Rehabilitation reputed company and VEVRAA, to reputed company and to advance in employment individuals with disability or protected veteran status, and to reputed company reputed company employment reputed company only on valid job requirements. This policy shall apply to reputed company employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at reputed company reputed company of employment.
Originally posted on Himalayas
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