Utilization Management Clinical Manager (RN)

The Utilization Management Clinical Manager RN is responsible for the overall management of the Utilization Management department. This includes overseeing the day-to-day operations of the department, as well as developing and implementing new programs and initiatives. The Manager is also responsible for ensuring that the department meets all regulatory requirements, and that the quality of care is maintained. The manager will be responsible for providing leadership and guidance to the team to ensure compliance with regulatory requirements and health plan policies. The position will report to the Director of Utilization Management and work closely with other departments to ensure timely and accurate utilization management decisions.

Salary: $115,000.00/annual

JOB QUALIFICATIONS: KNOWLEDGE/SKILLS/ABILITIES

The Utilization Management Clinical Manager RN’s responsibilities include but are not limited to:

Oversee the day-to-day operations of the Utilization Management department, including staffing, scheduling, etc.
Ensure that the department meets all regulatory requirements.
Maintain the quality of care provided by the department.
Provide leadership and direction to the team of LPNs, RNs, and utilization management coordinators.
Conduct performance reviews and provide feedback to staff.
Develop and implement training programs for staff.
Represent the department to other departments and stakeholders.
Ensure timely and accurate utilization management decisions.
Establish and maintain effective working relationships with health plan providers, including payers, physicians, and other providers.
Monitor and analyze utilization management data to identify trends and opportunities for improvement.
Develop and implement utilization management programs to improve quality and cost-effectiveness of health plan services.
Collaborate with other departments, such as Quality and Provider Relations, to identify and address utilization management issues.
Participate in internal and external audits of the utilization management process.
Maintain compliance with all accrediting agency standards such as NCQA, CMS and State agencies
Strong organizational skills, ability to adapt quickly to change and desire to work in a fast-paced environment
Team oriented and self-motivated with a positive attitude
Performs other duties as assigned

EDUCATION:

Active, unrestricted Registered Nurse
Bachelor's degree in nursing (BSN)

EXPERIENCE:

Bachelor's degree in nursing (BSN)
Registered Nurse (RN) licensure
Minimum of 3 years of nursing in an acute or outpatient setting
Minimum of 5 years of UM experience in a managed care, payor environment
Experience with New York Medicare and Medicaid.
Knowledge of regulatory requirements related to utilization management, such as CMS and NCQA standards
Strong communication, leadership and analytical skills
Ability to work effectively in a fast paced, team-oriented environment
Proficiency in Microsoft Office application and health plan systems
Experience with Medicare, Medicaid UM authorizations and appeals for DMEPOS
Experience with Medical Necessity Criteria including but not limited to InterQual, CMS guidelines, health plan medical policies, etc.
Verbal and written communication skills to convey information clearly and consistently

Benefits Offered

Competitive compensation and annual bonus program
401(k) retirement program with company match
Company-paid life insurance
Company-paid short term disability coverage (location restrictions may apply)
Medical, Vision, and Dental benefits
Paid Time Off (PTO)
Paid Parental Leave
Sick Time
Paid company holidays and floating holidays
Quarterly company-sponsored events
Health and wellness programs
Career development opportunities

Remote Opportunities

We are actively seeking new colleagues in: Arizona, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Kentucky, Massachusetts, Michigan, North Carolina, New Jersey, New York, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Vermont, and Washington.

Our Story

Founded in 2005, Integra Partners is a leading network management company specializing in Orthotics, Prosthetics, and Durable Medical Equipment. We are reimagining access to in-home healthcare to improve the quality of life for the communities we serve.

With locations in New York City and Michigan, plus a remote workforce across the United States, Integra has a culture focused on collaboration, teamwork, and our values: One Team, Drive Results, Push the Boundaries, Value Others, and Build Community. We’re looking for energetic, talented, and dedicated individuals to join our team. See what opportunities we have available; there may be a role for you to engage in a challenging yet rewarding career in healthcare. We look forward to learning more about you.

Integra Partners is an equal opportunity employer. We are committed to providing reasonable accommodations and will work with you to meet your needs. If you are a person with a disability and require assistance during the application process, please don’t hesitate to reach out. We celebrate our inclusive work environment and welcome members of all backgrounds and perspectives.

Utilization Management Clinical Manager (RN)

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