Medical Management Manager

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Provides administrative oversight and monitoring of the utilization review activities including the Utilization Management Program (UMP) development and implementation. Supervises professional nursing staff performing utilization management functions ensuring that members receive care and services that meet all contractual and regulatory requirements for quality, timeliness and access. Works with the Medical Directors to ensure availability of clinical guidance and support for clinical review staff. Implements the UMP to ensure that members receive care in the least restrictive setting by overseeing the consistent application of appropriately approved clinical criteria (e.g., InterQual). Works with the Medical Director and Senior Director of Medical Management and Quality Improvement (QI) management, in the successful implementation of the Quality Improvement Program as it relates to the UMP.

Primary Duties and Responsibilities:

• Manage the day to day operations while implementing the UM program and its role in the QI program.
• Develop and implement appropriate processes to facilitate effective management of members with both medical and behavioral health services in assuring service sites and levels of care are appropriate, monitoring services provided for continuity, cost effectiveness, medical necessity, and timeliness. Make recommendations to Senior Director of Medical Management and Chief Medical Officer for improvement of processes and services.
• In partnership with clinical department Managers, monitor patients for outlier and disability status and coordinates actions that will reduce the Plan’s liability.
• In partnership with clinical department Managers, collaborates to develop and implement an integrated and individualized care plan for members, as needed.
• Collect UM information and uses it for performance improvement and QI activities/initiatives as required by the QI program
• Assist in the oversight of any delegated UM arrangements if any such arrangements exist
• Work with the QI department to facilitate the annual review and approval of InterQual criteria
• Work closely with the Medical Directors, Pharmacists and Pharmacy Benefits Management to ensure quality, cost-effective utilization of pharmaceuticals.
• Ensure adequate and timely care review documentation, document preparation and maintenance which enables prompt response to claims submittal, regulatory agency audits and surveys and other internal and external requests for data.
• Participate in all contractual and regulatory audits involving the department, and to lead the department/staff in the audit preparations
• Participate in the Quality Improvement process to ensure that quality care and services are provided to the member in a timely manner. This includes the identification and referral of quality sentinel events identified during the provision of medical services including an inpatient confinement to the QI department for investigation
• Provide direction/guidance and training to plan staff and providers, as needed.
• Provide management and supervision to the department by:
a. Interviewing potential new hires, along with the department Lead, when staff vacancies occur
b. Hiring/disciplinary actions/terminating
c. Ensuring that effective orientation of new hires to position and training for job function, including new hire training tracking and periodic documented re-training of all department staff is implemented by the department Supervisor
d. Timely staff job performance review (JPR)
e. Salary & bonus determinations
f. Keeping Job Descriptions up to date
g. Scheduling staff including approving PTO requests, signing timesheets, and approving overtime
• Establish atmosphere of compliance with requirements within the department
a. Being aware and knowledgeable of key requirements (contractual, regulatory, accreditation) related to departmental and pertinent interdepartmental activities, and the reference materials supporting these
b. Ensure all P&Ps required are kept up to date, accurate and meeting requirements
c. Both for staff performance and core department functions, establish departmental performance measures and standards and develop performance monitoring tools/reports to allow for effective performance tracking and comparisons over time. Institute corrections for identified deficiencies, as necessary
d. Achieve department goals related to organizational priorities, contractual requirements or other established benchmarks
• With the Medical Director and department clinical staff, assures that additional factors and complications of member care are addressed if not covered in InterQual criteria such as: age; co-morbidities; complications; progress of treatment; psychosocial situation, and; home environment, when applicable. Assures that additional complications for member care are addressed on an individual basis such as:
1. Availability of skilled nursing facilities, sub-acute care facilities or same level of care provided in hospital if facilities are not available in the community
2. Works with case management to ensure availability of home care in the urban and rural service areas to support the patient after hospital discharge
3. Local hospitals’ ability to provide all recommended services within the estimated length of stay.
• Identify interdepartmental and organizational interdependencies
1. Ensure smooth execution of key interdependencies (organizationally and departmental)
• Ensure that continuing education needs of clinical and paraprofessional staff are in place
• Prepare budgets and monthly variance explanations
• Sign off on check requests for departmental expenditures
• Hold departmental meetings documented with minutes – including sharing non-confidential items of interests from Managers’ Meetings
• Participate in Managers meetings
• Participate in organizational workgroups or assigning other departmental staff to participate, as appropriate
• Perform administrative duties of the department Supervisor during absences or vacancies

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