UM Informed Choice Supervisor

Job Title

UM Informed Choice Supervisor

Department

UM Informed Choice

Reports to

Director, Medical Care Managament

Vice President

Medical Management

Updated

April 2025

Nature of Work in this Position: The primary responsibility of this position is to direct and oversee the medical utilization and contracts and provider relation programs for StayWell Plans. Under general direction of the Director of Medical Care Management, the incumbent will take responsibility for the daily management of prospective, concurrent, and retrospective utilization reviews including treatment pre-certification, case management, quality management, and hospital claims review.

Illustrative Examples of Work:

• Administer and directs the medical utilization management program to maintain standards of patient care, and advises staff healthcare professionals and administrators in matters relating to utilization management.
• Reviews staff work concerning admissions, treatment, and length of hospital stay of members.
• Supervise and performs the daily utilization activities of the department and acts as a liaison between participating hospitals and providers.
• Provides daily management of prospective, concurrent and retrospective utilization reviews including pre-certification of treatment, case management, quality management, and hospital claims review.
• Reviews application for member in-patient admission and concurs admission and refers case to the Director of Medical Care Management for review and course of action as daily protocol and/or when case fails to meet medical utilization management (admission) standards.
• Negotiates contracts with healthcare providers and educates providers on contract provisions.
• Promotes working relationships with community agencies and healthcare providers regarding the StayWell Plans.
• Recommends establishment or revision of policies and develops organizational structure and standards of performance.
• Interprets policies and objectives of utilization management to staff and provider groups.
• Assists in preparation of budget and administers program within budgetary limitations.
• Develops procedure manuals, initiates in-service programs, installs record and reporting system, and performs other personnel management tasks.
• Prepares daily and periodic reports.
• Performs related duties as required. (Related duties are duties that may not be specifically listed in the class specification or position description, but that are within the general occupational series and responsibility level typically associated with the employee’s class of work.)

Knowledge / Skills / Abilities:

• Significant organizational skills.
• Strong verbal and written communication.
• Attention to detail and quality focused.
• Ability to multi-task and manage time efficiently.
• Knowledgeable in pharmacy benefits management.
• Ability to perform medical utilization review.
• Ability to use national guidelines for case management.
• Knowledgeable in medical case management.
• Knowledgeable in HCPCS ICD coding.
• Knowledgeable in the use of health plan claims system.

Minimum Experience and Training:

Any combination of education and experience providing the required skill and knowledge for successful performance would be qualifying. Typical qualifications would be equivalent to:

• A Master’s or doctorate degree in Medical Science or Nursing (may be foreign equivalent); and
• Minimum of three (3) to five (5) years’ experience in medical coding, medical care management, or case management.
• Proficient in MCG, HCPCS ICD coding, and Health Plan Claims System;
• Proficient in the use of Microsoft Office (Excel, Word, PowerPoint, Outlook); and
• Computer literate (Windows).

Other Requirements:

• Desired: Bilingual speaking
• License: Medical or RN (may be foreign equivalent).
• Any national certification related to Health Care Administration.

Note: This job specification should not be construed to imply that these requirements are the exclusive standards of the position. Incumbents will follow any other instructions, and perform any other related duties, as may be required by their supervisor.

This job entails access to PHI / ePHI data. Any personally identifiable health information, including genetic and demographic data, collected from an individual by a covered entity. This includes information related to an individual's past, present, or future physical or mental health, healthcare provision, or payment. PHI includes information like the patient's name or other identifiable data. It excludes information in education records and employment records held by a covered entity. PHI also excludes information related to individuals who have been deceased for more than 50 years. The hired individual is expected to maintain policies and procedures to ensure compliance with HIPPAA regulations in handling PHI/ePHI data.

Pay: $18.64 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Work Location: In person