Senior Manager, Utilization Management

Responsibilities
•    Effectively manage the daily operations, workflow, and supervise clinical and non-clinical staff to provide support for the utilization management, benefits and service coordination and appeal process).
•    Assist in developing strategic plan by partnering with Director/Assistant Director and Fund management to identify opportunities that have direct impact on clinical and financial outcomes.
•    Access and analyze all processes on an ongoing basis to determine their effectiveness, eliminate inefficiencies, and make recommendations to senior management to improve workflow, operations, and staff performance. 
•    Coordinate activities between clinical programs, communication, and report requirements to maintain operational efficiencies and to be in compliance with the Department of Labor (DOL), Summary Plan Description (SPD) departmental protocols and clinical policies and procedures.
•    Interact and collaborate with other departments in troubleshooting, problem solving, and exchanging information in conjunction with maintaining effective communication with providers and members. 
•    Participate in interdepartmental committees/meetings.
•    Lead internal audits for designated unit
•    Develop and maintain ongoing quality insurance process
•    Responsible for staff development, clinical orientation, ongoing education, and training programs to meet the changing needs of the Department. 
•    Continually assess clinical staff performance against internal and external departmental and industry standards.
•    Perform additional duties and projects as assigned by managed

Qualifications
•    Bachelor’s Degree in Nursing, Business or Health Care Administration or equivalent years of work experience required; plus
•    Current New York State of Registered Nurse (RN) license required
•    Minimum six (6) years work experience in Utilization/Case Management/Appeals Programs within a managed care organization, to include a minimum of three (3) years progressive leadership and management experience
•    Experience working with Milliman guidelines or other regulatory protocols, claims processing, medical coding and interpreting provider contracts
•    Ability to make critical business clinical decisions independently.
•    Ability to work with automated Prior Authorization system
•    Intermediate level of Microsoft Office suite applications
•    Strong critical thinking and analytical skills with effective troubleshooting and problem-solving abilities
•    Excellent time management and project management skills
•    Effective verbal and written communication skills
•    Ability to prioritize and be detail-oriented, multi-task and must strive in fast-paced environment