utilization manager

MCS HEALTHCARE HOLDINGS, LLC

<div><p><b>Gerente De Manejo De Utilizacion</b></p><p><br>
Regular</p><p>
Exempt</p><p></p><p><b><br>
GENERAL DESCRIPTION:</b></p><p>
The Utilization Management Manager is responsible for overseeing the Utilization Management unit, ensuring effective implementation of policies, operational guidelines, and clinical protocols. This role involves leading and developing the team, monitoring performance, and driving compliance with organizational goals. The manager coordinates cross-departmental collaboration, manages work plans, tracks key metrics, and maintains accurate reporting. Additionally, they uphold confidentiality standards and foster strong relationships with internal and external clients to support efficient and compliant utilization management operations.
</p><p><b>ESSENTIAL FUNCTIONS:</b></p><ul><li>Creates, develops, and updates unit work plans, policies, operational guidelines, and clinical protocols to use in the unit. Develops activities to comply with policies, operational guidelines, and clinical protocols.</li><li>Responsible for ensuring compliance with the goals and objectives established for the Utilization Management unit.</li><li>Collaborates with other departments to achieve goals and objectives set by the Company.</li><li>Responsible for coordinating meetings with staff to keep them updated on the progress of the work plan, achievements, and corresponding metrics.</li><li>Responsible for coordinating and/or providing a development plan for the unit's personnel.</li><li>Responsible for developing unit compliance statistics and metrics.</li><li>Maintains monthly statistics of the activities carried out in the department and ensures that the required reports for each business line are produced promptly, correctly, and completely.</li><li>Maintains effective interaction with both internal and external clients.</li><li>Knows and complies with the confidentiality policy and monitors to ensure compliance.</li><li>Supervises, monitors, trains, evaluates, and corrects personnel among others to comply with his/her role as a supervisor, to assure that his/her personnel fulfill their work plan and comply with their essential functions and that they behave following the policies, standards, norms, and procedures of the Company.</li><li>Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.</li><li>May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.</li></ul><p><b>
MINIMUM QUALIFICATIONS:</b></p><p><b>
Education and Experience: </b>Bachelor's degree in Nursing Sciences. Five (5) years of experience in a health care environment and supervising staff.</p><p><b>
Certifications / Licenses: </b>A valid Nursing and Registration license is required. Other: Knowledge of clinical criteria, ICD-10, and CPT.</p><p><b>
Languages:</b></p><p>
Spanish &ndash; Advanced (comprehensive, writing and verbal)</p><p>
English &ndash; Advanced (comprehensive, writing and verbal)</p><p></p><p><b><br>
&ldquo;We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.&rdquo;</b></p></div>

Gerente De Manejo De Utilizacion

ECHO

<div><p><b>Primary Purpose:</b></p><p>
To provide support and facilitate care for members who require case management. To work collaboratively with the Health Plan and Hospital Case Management Departments to facilitate services. To collaborate with the treating physician and IPA Medical Director in the review and decision-making process regarding the provision of appropriate health care and service requests. Case Management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates an individual&rsquo;s health needs through communication and available resources to promote quality and cost-effective outcomes. If applicable, the CM will coordinate care for Cal Medi-Connect program members to ensure that all aspects of the CMC program description are implemented and followed. All services under Medicare and Medi-Cal will be coordinated and monitored, including CCS, IHSS, CBAS, and BH. The case manager is a licensed nurse (RN or LVN). A care manager can be a licensed social worker (MSW) or a licensed nurse (RN or LVN).</p><p>
All candidates for any position within case management will have the appropriate education and experience to meet requirements and the service needs of the population.</p><p><b>
Principal Duties and Responsibilities (* = essential functions):</b></p><ul><li>
To utilize the Case Management functions: assessor, planner, facilitator, advocate. *</li><li>
To facilitate services at the appropriate Health Plan center of excellence. *</li><li>
To utilize the most cost-effective case rates and contracts. *</li><li>
To review and process clinical information in accordance with regulatory mandates to facilitate patient healthcare and services across the continuum of care. *</li><li>
To perform catastrophic case management as appropriate to the patient&rsquo;s medical condition and healthcare needs, utilizing the standards of practice for Case Management.</li><li>
To interface professionally and courteously with all internal staff and external customers to ensure appropriate exchange of information. *</li><li>
Preparing for and participating in health plan audits onsite as required.</li><li>
To actively participate in Utilization Management Committees regarding Case Presentations and problem-solving.</li><li>
To participate in the development of Case Management Policies and Procedures.</li><li>
To actively participate in the discharge planning process.</li><li>
To monitor and participate in the SNP/Duals program</li><li>
To monitor and participate in the CMC program</li><li>
To ensure all members are living in the least restrictive environment</li><li>
To follow the UM/QI/CM/SNP/CMC program descriptions</li><li><b>
Assigned to On-Call after-hours Customer Service Care.</b></li><li>
To perform other duties as assigned.</li></ul><p><b>
Job Specifications (KSAs):</b></p><ul><li>
Requires extensive and specialized knowledge of utilization and case management processes, generally acquired through 2-3 years or more of experience as a case manager in a Managed Care Environment, or through successful completion of a nursing program.</li><li>
Requires prior Case Management experience, preferably with catastrophic cases.</li><li>
Requires an active RN or LVN license in the state of employment.</li><li>
Requires clinical expertise, generally acquired through 3 to 5 years of acute nursing practice.</li><li>
Requires excellent written and verbal communication skills.</li><li>
Requires computer experience, particularly with Microsoft Word and Excel, familiarity with Cozeva (a plus), and the ability to learn new software applications quickly.</li><li>
Requires problem-solving and critical thinking skills.</li><li>
Requires professional demeanor and the ability to contribute to a positive work environment.</li><li>
Requires knowledge of regulatory standards such as Medicare, TitleXXII, and Medi-Cal*</li><li>
Requires extensive knowledge of health plan guidelines.</li></ul><p><b>
Position Performance Criteria:</b></p><ul><li>
Demonstrates proficiency in UM and Case Management, including but not limited to:</li></ul><ul><li>
Catastrophic Case Management</li><li>
Transplant Management</li><li>
Referral review</li><li>
Out-of-network management</li><li>
Denial letter process</li><li>
Concurrent/inpatient review and bed-day management.</li><li>
Demonstrates the effective practice of Case Management Standards of Care, including:</li></ul><ul><li>
Assessment</li><li>
Case Identification and Selection</li><li>
Planning</li><li>
Monitoring</li><li>
Evaluating</li><li>
Outcomes</li><li>
Sets appropriate priorities to meet departmental goals and objectives, including but not limited to:</li></ul><ul><li>
Demonstrates ability to efficiently manage case load.</li><li>
Demonstrates ability to set appropriate priorities</li><li>
Consistently makes prudent and sound decisions</li><li>
Manages multiple tasks while meeting required timeframes</li><li>
Adheres to departmental policies and procedures</li></ul><ul><li>
Demonstrate knowledge of Health Plan guidelines.</li><li>
Demonstrates knowledge of federal, state, NCQA, and health plan regulatory requirements and approved criteria guidelines.</li></ul><ul><li>
Ensures consistency in the application of the utilization process.</li><li>
Maintains knowledge of new legislation and disseminates information to providers and co-workers.</li></ul><ul><li>
Demonstrates ability to give concise, articulate, and accurate case presentations to Medical Director, UMC, etc., including problem-solving.</li><li>
Demonstrates cost savings.</li><li>
Consistently demonstrates professional work ethic, collegial interaction with others, and reliability, while contributing to a positive work environment, including but not limited to:</li></ul><ul><li>
Professional appearance and demeanor</li><li>
Meets departmental attendance needs on-site</li><li>
Participates verbally in group activities, i.e., staff meetings, etc.</li><li>
Demonstrates respect for co-workers and customers.</li><li>
Works collaboratively with other departments to identify and resolve issues.</li></ul><p></p><p><br>
Hourly Range is: $33.50 to $45.00 per hour</p></div>

Inpatient Nurse Case Manager

Yale New Haven Health

<div>Overview:
<div>
To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.<br>
<br>
The Case Manager is responsible and accountable for ensuring high-value patient care that is coordinated, efficient, and aligned with institutional clinical and financial objectives. In collaboration with the healthcare team, the Case Manager utilizes evidence-based practice to ensure that specific patient outcomes are reliably achieved and that resources are appropriately used within designated fiscal time frames. With our members of the health care team, the Case Manager participates in the ongoing evaluation of practice patterns and supports efforts to improve patient care and enhance the efficiency of operations. The Case Manager interacts with others in the identification of trends and barriers to all aspects of care. Through this interaction, the Case Manager identifies and works toward a resolution as a part of the multidisciplinary team.<br>
<br>
EEO/AA/Disability/Veteran</div>
Responsibilities:
<ul><li><div>1. As part of the interdisciplinary health care team, coordinates and ensures the implementation of the plan of care, utilizing the principles of case management.</div></li><li><ul><li><div>
1.1 Establishes a system for coordinating the care of a patient throughout the continuum of care, linking the inpatient care with outpatient care, services, and case management.</div></li></ul></li><li><div>
2. Optimizes the efficiency of hospital systems which impact quality and/or length of stay</div></li><li><ul><li><div>
2.1 Identifies and monitors compliance with documenting variances from established parameters in the clinical pathway or treatment plan.</div></li></ul></li><li><div>
3. Utilizes information obtained from various resources available to:</div></li><li><ul><li><div>
3.1 Ensure that each patient meets the clinical needs for admission, treatment, and discharge and initiates appropriate follow through with the health care team.</div></li></ul></li><li><div>
4. Assist clinicians in documenting the appropriateness of admissions and continued stays</div></li><li><ul><li><div>
4.1 Responsible for Medicare notices of non-coverage and help provide appropriate documentation to appeal inappropriate denials.</div></li></ul></li><li><div>
5. Ensures that an appropriate discharge plan is developed and implemented with the health care teams members to include:</div></li><li><ul><li><div>
5.1 Identifying service, treatment, and funding options;</div></li></ul></li><li><div>
6. Ensures that the discharge plan provides a continuum of care with the appropriate outpatient physician and needed services.</div></li><li><div>
7. Ensure that the appropriate outside agencies are contacted and necessary referrals are initiated and followed through.</div></li><li><ul><li><div>
7.1 Links patient and family with the appropriate institutional or community resources, advocating on their behalf for scarce resources, and developing new resources where gaps exist in the service continuum.</div></li></ul></li><li><div>
8. Works collaboratively with PSM and unit leadership team to actively involve clinical nurses in the assessment and planning for patient's discharge to facility.</div></li><li><div>
9. Along with other members of the health care team, acts as a patient advocate.</div></li><li><ul><li><div>
9.1 Exhibits awareness of ethical/legal issues concerning patient care and strives to manage situations to reduce risk.</div></li></ul></li></ul>
Qualifications:
<div>
EDUCATION</div><div></div><div><br>
Minimum of a Baccalaureate degree in clinically related field. R.N. required</div><div></div><div><br>
EXPERIENCE</div><div></div><div><br>
Minimum of three (3) years of relevant clinical experience</div><div></div><div><br>
LICENSURE</div><div></div><div><br>
Active RN Licensure in Connecticut</div><div></div><div><br>
SPECIAL SKILLS</div><div></div><div><br>
Recent appropriate nursing experience, theoretical knowledge of the nursing process, case management and continuity of care. Advanced communication and interpersonal skills with all levels of internal and external customers. Ability to obtain and interpret information appropriate to patient needs and age. Advanced assessment and teaching skills. Leadership skills in planning and managing patient care as acquired through greater than 3 years of clinical nursing experience in an acute care hospital. Utilization management and case management experience preferred. Knowledge of computer software and hardware applications and a basic knowledge of statistics.</div><div></div><div><br>
PHYSICAL DEMAND</div><div></div><div><br>
50% sedentary; sitting, standing, walking from unit to unit, carrying records, speaking before groups. Must be able to speak and hear in a manner understood by most people. Must be able to communicate effectively by telephone.</div></div><div></div>

Case Manager

SSM Health

<div><div><p><b>It's more than a career, it's a calling.</b></p>
MO-REMOTE<p></p><p><b>
Worker Type:</b></p>
Regular<p></p><p><b>
Job Summary:</b></p>
Serves as the Utilization Management system-wide point of coordination between regional clinical and operational team leaders, physician liaisons, and revenue cycle leaders.<p></p><p><b>
Job Responsibilities and Requirements:</b></p><p>
PRIMARY RESPONSIBILITIES</p><ul><li>
Serves as the direct resource for the regional physician liaisons regarding Utilization Management (UM) initiatives and regional specific UM issues.</li><li>
Performs audits on UM denial write off accounts to ensure accurate categorizing of the root cause of denial and to identify potential opportunities for claims re-bill.</li><li>
Collaborates with Managed Care Organization (MCO) team members to stay abreast of contractual updates to develop and maintain UM payer grids with contractual requirements.</li><li>
Serves as a UM subject matter expert on state and federal regulatory requirements related to UM processes.</li><li>
Represents the system UM team on committees and work groups as assigned by leadership.</li><li>
Presents critical messages and complex information and reports to UM leadership.</li><li>
Provides responses to questions and concerns raised by physician liaisons, clinical and operational team members, providers, and UM leaders.</li><li>
Supports UM leadership and collaborating teams and providers with resources, data, and education to improve UM outcomes.</li><li>
Applies the existing body of evidence-based practice and scientific knowledge in health care to medical-surgical nursing practice, ensuring that nursing care is delivered based on patient&rsquo;s age-specific needs and clinical needs as described in the department's Scope of Service.</li><li>
Performs other duties as assigned.</li></ul><p></p><p>
EDUCATION</p><ul><li>
Graduate of accredited school of nursing or education equivalency for licensing</li></ul><p></p><p>
EXPERIENCE</p><ul><li>
Two years' acute nursing experience, four years of Utilization Management experience</li></ul><p></p><p>
PHYSICAL REQUIREMENTS</p><p>
Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.<br>
Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.<br>
Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.<br>
Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.<br>
Frequent keyboard use/data entry.<br>
Occasional bending, stooping, kneeling, squatting, twisting and gripping.<br>
Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.<br>
Rare climbing.</p><p></p><p>
REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS<br>
<br>
State of Work Location: Illinois</p><ul><li>
 Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)</li></ul><p><br>
<br>
State of Work Location: Missouri</p><ul><li>
 Registered Nurse (RN) Issued by Compact State</li><li>
 Or</li><li>
 Registered Nurse (RN) - Missouri Division of Professional Registration</li></ul><p><br>
<br>
State of Work Location: Oklahoma</p><ul><li>
 Registered Nurse (RN) Issued by Compact State</li><li>
 Or</li><li>
 Registered Nurse (RN) - Oklahoma Board of Nursing (OBN)</li></ul><p><br>
<br>
State of Work Location: Wisconsin</p><ul><li>
 Registered Nurse (RN) Issued by Compact State</li><li>
 Or</li><li>
 Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services</li></ul><p></p><p><b>
Work Shift:</b></p>
Day Shift (United States of America)<p></p><div><div><div><div><div><div><div><p><b>
Job Type:</b></p></div></div></div></div></div></div></div>
Employee<p></p><p><b>
Department:</b></p>
8746030033 Sys Utilization Management<p></p><p><b>
Scheduled Weekly Hours:</b></p>
40<p></p><p><b>
Benefits:</b></p><p></p><p>
SSM Health values our exceptional employees by offering a comprehensive benefits package to fit their needs.</p><p></p><ul><li><p><b>
Paid Parental Leave</b><b>:</b> we offer eligible team members one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE).</p></li><li><p><b>
Flexible Payment Options:</b> our voluntary benefit offered through DailyPay offers eligible hourly team members instant access to their earned, unpaid base pay (fees may apply) before payday.</p></li><li><p><b>
Upfront Tuition Coverage</b>: we provide upfront tuition coverage through FlexPath Funded for eligible team members.</p></li></ul><p></p><p>
Explore All Benefits</p><p></p><p><i>
SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity,</i><b><i> </i></b><i>pregnancy, veteran status</i><b><i>, </i></b><i>or any other characteristic protected by applicable law. </i><i>Click here to learn more.</i></p></div></div>

RN-Utilization Management and Denials Liaison

Detroit Wayne Mental Health Authority

<p></p><div><p>Under the supervision of the DWIHN Call Center Director, the Substance Use Disorder (SUD) Technician is responsible for conducting brief screenings, electronic case review and providing authorization and care management services. This position is responsible for providing behavioral health utilization management services for the treatment provider network through the implementation and facilitation of outpatient, withdrawal management, residential authorizations and case management processes.</p><p><br>
</p><p><b>Principle Duties and Responsibilities:</b></p><ul><li>
Determines appropriate levels of care for referral, assisting clients in selecting an appropriate SUD provider.</li><li>
Initiates referrals to selected provider.</li><li>
Conducts initial intakes.</li><li>
Discusses with the client the rationale, purpose, and procedures associated with the screening and assessment process to facilitate the client&rsquo;s understanding and cooperation.</li><li>
Gathers and assesses information and summarizes data for the client.</li><li>
Assesses and determines the severity of client&rsquo;s substance use disorder.</li><li>
Assesses client&rsquo;s immediate needs by evaluating relevant information including signs and symptoms of intoxication and withdrawal.</li><li>
Administers appropriate evidence‐based screening and assessment instruments specific to each client to determine their strengths and needs.</li><li>
Obtains relevant history and related information from the client and other pertinent sources to establish eligibility and appropriateness of services.</li><li>
Interprets results of screening and assessments and integrates all available information to formulate a diagnostic impression and determine an appropriate course of action.</li><li>
Develops a written summary of the results of the screening and assessment to document and support the diagnostic impressions and treatment recommendations.</li><li>
Formulates and discusses diagnostic assessment and recommendations with the client to initiate an individualized treatment plan that incorporates client&rsquo;s strengths, needs, abilities, and preferences.</li><li>
Performs ongoing assessments in collaboration with the client and concerned others to review and modify the treatment plan to address treatment needs.</li><li>
Matches client needs with community resources to facilitate positive client outcomes.</li><li>
Discusses rationale for a referral with the client.</li><li>
Communicates with community resources regarding needs of the client.</li><li>
Provides information to the client regarding the structure, expectations, and purpose of the counseling and referral process.</li><li>
Provides continual evaluation of the client&rsquo;s safety, relapse potential, and the need for crisis intervention.</li><li>
Provides information on issues of identity, ethnic background, age, sexual orientation, and gender as it relates to substance use, prevention and recovery.</li><li>
Provides re-authorization of SUD/Mental Health/co-occurring services.</li><li>
Conducts three-way warm transfer calls.</li><li>
Assists providers with additional client information to assure appropriate referral for treatment services.</li><li>
Evaluates clinical appropriateness for SUD consumers.</li><li>
Establishes funding eligibility.</li><li>
Applies priority status criteria for placement.</li><li>
Responsible for follow-up with clients who were admitted for treatment and assisting them with a continuum of care.</li><li>
Monitors client&rsquo;s compliance with services and assists with aftercare/recovery plan services.</li><li>
Reviews requests for authorizing/reauthorizing medically appropriate services and length of stay.</li><li>
Manages client care through the MH-WIN system.</li><li>
Updates the reauthorizations database.</li><li>
Tracks and monitors cost factors relative to service utilization,<br>
 treatment activities, and other access and placement criteria.</li><li>
Conducts utilization reviews of SUD/COD client cases daily.</li><li>
Conducts SUD provider authorizations and reauthorizations for SUD/COD services.</li><li>
Enters data and reports into written formats and electronic databases.</li><li>
Monitors provider services for adherence to priority Federal, State and Medicaid admission requirements.</li><li>
Manages and coordinates waiting list(s) for those seeking SUD treatment by closely monitoring of provider capacity.</li><li>
Conducts SUD follow-up surveys and discharge summary reports for clients receiving intensive SUD services.</li><li>
Conducts client satisfaction surveys.</li><li>
Provides community callers with information related to community resources and assists callers with information on how to access community services.</li><li>
Utilizes computer to perform clinical and administrative job functions.</li><li>
Performs related duties as assigned.</li></ul><p><br>
</p><p><b>KNOWLEDGE, SKILLS AND ABILITIES (KSA&rsquo;s)</b></p><ul><li>
Knowledge of DWIHN policies, procedures and operations.</li><li>
Knowledge of the DWIHN provider network.</li><li>
Knowledge of medical and behavioral health practices and terminology.</li><li>
Knowledge of Customer Service practices and principals.</li></ul><ul><li>
Knowledge of co-occurring and substance use treatment services.</li><li>
Knowledge of the American Society of Addiction Medicine Patient Placement Criteria (ASAM) and the Federal Confidentiality Regulations, 42 CFR, Part 2.</li><li>
Knowledge of SUD Policies and Procedures.</li><li>
Knowledge of various treatment modalities including Opiate Maintenance Treatment (OMT) (and re-authorization of Medication Assisted Treatment (MAT) criteria), case management, chemically-dependent pregnant women, co-occurring individuals, SMI/SED and I/DD populations.</li><li>
Knowledge of Substance Abuse Administrative Rules requirements.</li><li>
Knowledge of SUD CPT codes.</li><li>
Knowledge of women specialty services requirements.</li><li>
Knowledge of priority population admittance.</li><li>
Knowledge of State Disability Assistance (SDA).</li><li>
Knowledge of Intravenous Drug User (IDU) management.</li><li>
Computer skills</li><li>
Time management skills</li><li>
Organizational skills</li><li>
Critical thinking skills</li><li>
Decision Making skills</li><li>
Customer Service skills</li><li>
Language skills</li><li>
Listening skills</li><li>
Teamwork skills</li><li>
Ability to communicate orally.</li><li>
Ability to communicate in writing.</li><li>
Ability to work effectively with others.</li><li>
Ability to work with an ethnically, linguistically, culturally, economically and socially diverse population.</li><li>
Judgement/Reasoning ability.</li></ul><p><br>
</p><p><b>Required Education:</b></p><ul><li>
A Bachelor&rsquo;s Degree from a recognized college or university in a Human Service, Social Service, Public Health, Public Administration, Healthcare Administration, Health Management or a related field.</li></ul><p></p><p><b><br>
Required Experience:</b></p><ul><li>
Three (3) years of full-time paid experience working in a human service or social service field.</li><li>
Experience must have also included: providing access authorization, access overrides, and utilization review.</li></ul><p></p><p><b><br>
Required License(s):</b></p><ul><li>
Certification as a Certified Addiction Drug Counselor (CADC) or Certified Advanced Addiction Drug Counselor (CAADC) by the Michigan Certification for addiction Professional (MCBAP).</li></ul><p></p><p><br>
NOTE: Applicants with an approved development plan by MCBAP will be accepted.</p><p></p><p><b><br>
Working Conditions</b></p><p>
Work is usually performed in a home/office setting.</p><p>
Contingent staff are allowed to work remotely with management approval.</p><p></p><p><b><br>
NOTE: The DWIHN Call Center is a 24/7 operation. Employees in the Call Center may be required to work one of three shifts (Days, Afternoons, Midnights) and weekends.</b></p><p><b><i>
This description is not intended to be a complete statement of job content, rather to act as a general description of the essential functions performed. Management retains the discretion to add or change the position at any time.</i></b></p><p></p><p><b><br>
Please Note: DWIHN requires proof of being fully vaccinated for COVID-19 as a condition of employment. Medical or religious accommodations or other exemptions that may be required by law, will be approved when properly supported. Further information will be provided during the recruitment process.</b></p><p></p><p><b><br>
DWIHN is an Equal Opportunity Employer</b></p></div><p></p>

Call Center SUD Technician Contingent

TEEMA

<div><ul><li><p><b>13 week contract</b></p></li><li><p><b>
REQUIRED: 5+ years case management experience with 2+ years recent acute inpatient case management experience</b></p></li><li><p><b>
BSN or MSW, Current MI RN licensure or LMSW, Discharge planning experience.</b></p></li><li><p><b>
There will be limited training on site - candidates will need to be able to adapt quickly.</b></p></li><li><p><b>
Manager will be reaching out to candidates directly for interview</b></p></li><li><p><b>
 MANAGER IS VERY STRICT ON THE RECENT INPATIENT CASE MANAGEMENT EXPERIENCE - TELEPHONIC, UTILIZATION REVIEW, PSYCHOLOGICAL EXPERIENCE DOES NOT APPLY TO THIS REQUIREMENT.</b></p></li></ul><br>
<p></p>
#Workwolf</div>

PerksHR

<p>JOB DESCRIPTION:</p><p><b>Purpose of the Role</b></p><p>The Senior Manager &ndash; Claims is responsible for overseeing and monitoring claims evaluation and payments for both network and non-network hospitals, ensuring compliance with SLAs and SOPs, timely settlement for clients and service providers, effective utilization control, and minimization of loss ratio.</p><p><b>Key Responsibilities</b></p><ul><li>Supervise evaluation of network and non-network claims in line with approved SLAs and SOPs.</li><li>Identify and prevent overpayments or undue payments to service providers.</li><li>Highlight and address areas of concern related to claims settlement between service providers and HID.</li><li>Resolve day-to-day operational issues within the claims department efficiently.</li><li>Assist in monitoring team workflow, productivity, target achievement, and completion of objectives.</li><li>Ensure timely and accurate preparation of monthly, quarterly, and annual claims ratio reports.</li><li>Coordinate closely with internal teams, branches, and external stakeholders to ensure smooth claims operations.</li><li>Perform any other tasks as assigned by management within defined timelines.</li></ul><p><b>Requirements</b></p><ul><li><b>Education:</b> MBBS</li><li><b>Experience:</b> 8&ndash;10 years of relevant experience</li><li><b>Industry:</b> Insurance (Health Claims preferred)</li><li><b>Skills:</b></li><li>Health insurance claims management</li><li>Claims evaluation &amp; utilization control</li><li>Strong analytical and reporting skills</li><li><b>Behavioral Competencies:</b></li><li>Strong leadership and people management skills</li><li>Problem-solving and decision-making ability</li><li>Effective communication and coordination</li></ul><p>Job Type: Full-time</p><p>Pay: Rs200,000.00 - Rs225,000.00 per month</p><p>Work Location: In person</p>

Senior Manager Claims-(PHR/1001/3)

Search 5137+ Utilization manager jobs near you this June. New roles added regularly across leading industries. Apply today.

5137 utilization manager jobs Near Me

Gerente De Manejo De Utilizacion

Inpatient Nurse Case Manager

Case Manager

RN-Utilization Management and Denials Liaison

Call Center SUD Technician Contingent

Case Manager

Senior Manager Claims-(PHR/1001/3)