Utilization Management Manager

4 days ago

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Vālenz® Health

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Vālenz® Health is a comprehensive health plan solutions provider that offers a fully integrated platform designed to simplify the complexities of healthcare for employers, payers, providers, and members. The company focuses on enhancing quality and lowering costs through data-driven insights, member navigation, provider networks, and robust claims management. By connecting various stakeholders in the healthcare ecosystem, Vālenz aims to improve health outcomes and streamline the healthcare experience for all involved.

Bill Review • Out-of-Network Repricing • Primary PPO and Alternative Repricing Administration • EDI and Clearinghouse Solutions • Medical Management

501 - 1000 employees

Founded 2004

⚕️ Healthcare Insurance

💳 Fintech

☁️ SaaS

📋 Description

• Provide oversight and operational leadership for the Utilization Management Program. • Ensure services are delivered effectively and efficiently. • Manage the day-to-day operations and drive continuous improvements and innovations in care management practices. • Oversee, evaluate, and maintain clinical program productivity, KPIs, and performance standards. • Generate and analyze outcome reports to guide staff in improving clinical and financial outcomes for clients. • Implement enhanced quality review processes for timely supervisory case reviews. • Ensure adherence to confidentiality, HIPAA standards, and URAC compliance. • Maintain compliance with federal, state, and local regulations. • Conduct annual performance evaluations, create improvement plans, and manage staff terminations. • Lead hiring, training, and development of new care staff. • Collaborate with the VP, Care Management on performance-related issues. • Spearhead accreditation efforts, focusing on successful URAC reaccreditation. • Ensure current products are delivered effectively and utilize best practices to develop opportunities for improvements. • Develop and maintain knowledge of cultural differences and socioeconomic factors affecting care. • Collaborate with other departments for integrated administrative activities and clinical operations. • Promote coordination and communication within the company regarding quality improvement and clinical operations.

🎯 Requirements

• Bachelor’s degree in Nursing (BSN) or related education degree. • Five (5) or more years of experience in a supervisory role managing health care programs and associated clinical staff. • Five (5) or more years of experience in utilization management, capable of effectively handling cases across all age groups and a wide range of medical conditions. • Experience with MCG (Milliman Care Guidelines) and NCCN for clinical reviews. • Experience in a managed health care program setting, with a deep understanding of utilization management. • Proficient knowledge of NCQA, URAC, or similar accreditation standards and previous participation in accreditation surveys. • Excellent communication and interpersonal skills, capable of effectively engaging with healthcare professionals, clients, and stakeholders at all levels. • Demonstrated ability to implement strategic plans, adhere to budgets, and provide insights for efficient operation and growth. • An active, unrestricted RN license in the state of residence, including a compact license. • Certification in a URAC recognized field. • A plus if you have MSN, MBA, or related degree in healthcare administration. • MCG Certification • Knowledge of self-funded plans, MGU, or stop-loss.

🏖️ Benefits

• Competitive benefits package with generous employer subsidies • Flexible and remote working options • 401k with generous employer match and immediate vesting • Personal and professional development opportunities • Supportive family benefits, including paid leave for new family members • Companywide philanthropic program, Valenz Communities Connection