Manager, Utilization Management – MA RN License

🔥 18 hours ago

🍂 Massachusetts – Remote

🍂 Massachusetts – Remote

💵 $83k - $132.8k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Oversee all utilization management activities to ensure consistency of services and achievement of utilization targets • Coordinate and manage the pre-determination process for medical and dental services • Ensure consistent application of authorization criteria and appropriate clinical review of denial or reduction decisions • Develop integrated service delivery and oversee utilization management data and processes • Manage benefits in alignment with state-based regulations, NCQA and/or URAC regulations, and CareSource policies • Review and revise workflows to maximize efficiencies • Monitor productivity and utilization trends • Oversee CQI activities, audits, and regular staff feedback • Report utilization management regulatory requirements and ensure compliance • Maintain utilization management reporting and trend data • Analyze under- and over-utilization impacts on member quality of care and outcomes, and formulate data-based recommendations • Develop, maintain, and update departmental policies and procedures • Ensure notices of adverse action comply with required regulations • Audit predetermination requests, documentation cases, and interrater reliability • Liaise with other departments on research and intervention • Perform other job-related instructions as requested

🎯 Requirements

• Associate’s Degree in Nursing is required • Current, unrestricted licensure in state of practice as a Registered Nurse (RN) is required • Minimum of five (5) years of clinical experience is required • Minimum of five (5) years of experience in case management, utilization management, and/or quality improvement is required • Two years of utilization management experience is preferred • Managed care experience is preferred • Beginning Excel, Word and PowerPoint experience • Experience in data analysis and trending • Knowledge of utilization management standards and practices • Management and prior supervisory skills • Familiarity with the health care field • Critical listening and thinking skills • Training/teaching skills • Strategic management skills • Negotiation skills/experience • Technical writing skills • Leadership experience and skills

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Substantial and comprehensive total rewards package • Employee total well-being support