Manager, Utilization Management Department

This position is located at our Washington, DC office with a requirement of 1-2 days onsite.

The Mgr II HCMS is responsible for managing a team of physical and/or behavioral health practitioners in the development, implementation, and coordination of a comprehensive integrated Medical Management program designed to manage health outcomes in a highly complex member populations with varying degrees of medical complexity and acuity. Participates in case and/or utilization management execution/decision making for managed member populations. Primary duties may include, but are not limited to:

• Engages in the development and implementation of integrated medical management programs across the different member population types covered by the health plan.

• Ensures continued compliance with specific medical management standards.

• Engages in the development process for medical and clinical management policy, procedures, and strategies.

• Evaluates medical, mental health, and substance abuse services for cost containment, to include complex/specialized member populations.

• Ensures program deliverables and compliance by monitoring established goals and implementing improvement strategies.

• Takes the lead within assigned area on ensuring the unit is positioned and prepared to execute on quality initiatives and activities including clinical indicators reporting, focus studies, HEDIS reporting and adherence to National Committee for Quality Assurance (NCQA) standards.

• Hires, trains, coaches, counsels, and evaluates performance of direct reports.

Requirements

• BA/BS in a related Health/Nursing field and minimum of 6 years of experience as aligned to appropriate license which includes 3 years prior management experience; or any combination of education and experience, which would provide an equivalent background.

• Current active unrestricted RN, LCSW, LPC, LMHC or other accepted license (as allowed by applicable state laws) and any other state or federal requirements that may apply is required.

• Masters in related Health/Nursing field preferred.

• Certified Case Manager Certification preferred.