Verda Healthcare, Inc. has a contract with the Center of Medicaid and Medicare Services (CMS) and Texas Department of Insurance (TDI) for a Medicare Advantage Prescription Drug (MAPD) plan for 2024. We are looking for a Senior Manager of UM/QI to join our growing company with many internal opportunities.
Are you ready to join a company that is changing the face of health care across the nation? Verda Healthcare, Inc. is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity.
Align your career goals with Verda Healthcare, Inc. and we will support you all the way.
Position Overview
As the Sr. Manager for UM/QI, you’ll have the opportunity to make a difference in the lives of our members. You’ll be responsible for managing a team who is providing clinical review of cases using standard criteria to determine the medical appropriateness of inpatient and outpatient services while supporting our members through assessment, care and conservation. You’ll serve as an advocate for our members, coordinating care and ensuring they have the necessary resources and support to achieve their health goals (recovering from an illness, improving quality of life, overall well-being, etc.). In this position, you will assist in the development of all the processes and procedures for Utilization Management, Quality Management, and Clinical Appeals. You will also assess the quality of service of Utilization Management and all programs and processes.
Essential Functions:
- Experience applying medical management treatment guidelines, such as InterQual, Milliman, or other practical management guidelines.
- In-depth knowledge of all aspects of managed care medical management including UM/CM, Grievance and Appeals, inpatient and outpatient services, medical policy.
- Maintain monthly departmental reports, track and trend results and report to senior leadershipinaccordance with departmental key performance indicators.
- To perform this job successfully, an individual must have basic knowledge andskillsusingMicrosoft Office including Word, Excel, and PowerPoint software; Internet software; Database software.
Responsibilities:
- Collaborating with departments outside of Medical Management to enhance the organization's utilization management capabilities and facilitate successful execution.
- Responsible for providing hands-on operational expertise and leadership to the company’s UM/QI services.
- Overseeing all aspects of UM/CM pertaining to medical services.
- Assisting with program planning, design, implementation, analytics, report preparation, supervision, and staff development.
- Develop and maintain applicable policies and procedures that meet applicable regulatory, accreditations, and business needs as approved by UM/QI Leadership.
- Completes Quality Assurance review/chart audit process for UM employees.
- Coordination of the denial process with the Director of UM/QI, and the UM Medical Director.
Minimum Qualifications:
- Graduate from an accredited school for Nursing
- Active and unrestricted Texas RN license
- Minimum 5 years Utilization Management experience in a health plan, IPA, or medical group setting
- 2 years of management or supervisory experience
Professional Competencies
- Certification in Case Management preferred.
- Bachelor’s prepared Nurse (BSN).
- 5 years’ experience in clinical and/or managed care required.