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POSITION SUMMARY
This position provides oversight of the utilization review, prior authorization and case management staff and activities. This position supervises personnel and participates in selection, orientation, training, counseling, evaluation and team scheduling. Provides leadership and guidance to staff and supervisors.

CORE FUNCTIONS
1. Leads and manages prior authorization, concurrent review, and case management staff within Medical Management in metropolitan and rural communities. Ensures quality of service and consistency is maintained. Develops workflows and processes that support accurate and timely responses to issues. Serves as a resource to other team members.

2. Participates in selection, orientation, and training of staff within the Medical Management Programs. Trains, orientates, develops, and evaluates employees. Evaluates performance and makes recommendations for improvement.

3. Communicates with PA, CM and UM departmental staff and management to ensure that there is implementation of new desk tops and policies to comply with AHCCCA, CMS and HCGA requirements and Health Plan goals. Develops work standards for area functions. Monitors processes and implements changes as needed for efficiency.

4. Collaborates with Management staff and Medical Directors to review cases and data for appropriateness of care, resource care, and achievement of budgetary targets.

5. Conducts audits and routine performance reviews.

6. Participates in or coordinates rounds, departmental meetings, quality teams, and other committees to ensure collaboration with other departments and compliance with State mandates.

7. Performs other related duties, including on-call, as assigned, and which are consistent with the goals and qualifications of this position.

8. This position may supervise others in the medical management systems of prior authorization and case management. Internal customers include medical management medical claims review, risk adjustment, and denials. Other internal customers include physicians, hospital administration, department directors, and employees. External customers may include vendors, other physicians, and health plan members. The incumbent conducts himself/herself to favorably represent the hospital in a variety of activities

MINIMUM QUALIFICATIONS

Completion of an Associate’s degree in Nursing.

Current AZ RN license permitting work in the State of Arizona.

Five years of clinical RN experience in prior authorization, utilization review, or case management, with one year of experience in a supervisory or management role. Knowledge of utilization management data analysis. Knowledge of Medicare, Medicaid, and Managed Care, CPT, ICD-10 and HCPCS codes. Skill in preparing and presenting detailed information to ensure understanding for a wide audience base. Skill in organizing work and providing critical thinking to resolve problems. Skill in communicating with all levels of the organization. Skill in conducting utilization data analysis and providing recommendations. Skill in oral and written communication. Ability to organize and execute programs. Ability to work independently to identify, develop, monitor, evaluate, and report on projects Ability to perform ongoing and objective projects ensuring all deadlines are met. Ability to be flexible to work on a variety of initiatives simultaneously under tight time constraints. Ability to build and maintain professional working relationships with all levels of support staff, providers, administrative staff and all internal and external customers.

Skill in computer applications including Microsoft Office Products and other medical management systems.

PREFERRED QUALIFICATIONS

Related certification(s) such as CCM, MCG certification, RN-BC, CMAC, Case Management Administrator preferred.

Additional related education and/or experience preferred.

EOE/Female/Minority/Disability/Veterans

Our organization supports a drug-free work environment.

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