Manager, Utilization Management - Must have a MA RN License
# Manager, Utilization Management - Must have a MA RN License **CareSource** · United States · `Remote` · `Full Time` 💼 **Уровень роли:** `Manager` 💰 **Компенсация:** `$83,000 – $132,800` 🕒 **Статус:** *Опубликовано: сегодня* · *Источник: Himalayas (JSON API)* --- ### Top Skills & Match 🎯 **Ключевой стек роли:** `[Utilization-Management]` `[Case-Management]` `[Nursing-Management]` `[Quality-Improvement]` `[Utilization-Management-Manager]` `[Utilization-Management-Supervisor]` `[Utilization-Review-Manager]` `[Healthcare-Utilization-Manager]` --- ### About the Role Job Summary: The Manager, Utilization Management is responsible for the oversight of all utilization management activities ensuring consistency of services and achievement of utilization targets. Essential Functions: - Assist in coordination and management of the pre-determination process of medical and dental services; ensure the consistent application of criteria for authorization decision, and that decisions to deny or reduce services are made by a health care professional who has appropriate clinical expertise - Assist in the development of integrated service delivery to members and oversee utilization management data and processes to maintain industry standards and practices including decisions within allowable timeframes - Interact with providers and staff to manage benefits aligned with state-based regulations, NCQA and/or URAC regulations, and CareSource policies - Review and revise workflows to maximize efficiencies - Monitor productivity and utilization trends - Oversee CQI activities and ensure audits and staff feedback occur at regular intervals - Regularly report all utilization management regulatory requirements - Ensure compliance with and reporting of all regulatory requirements - Maintain all utilization management reporting and trend data - Analyze under and over utilization information for impact on member quality of care and outcomes and formulate recommendations based on data - Develop, maintain and update all departmental policies and procedures; ensure notices of adverse action are provided in accordance with required regulations - Audit predetermination requests, cases for documentation and interrater reliability per CareSource policy - Act as liaison with other departments to assist with research and intervention - Perform any other job related instructions, as requested Education and Experience: - Associate’s Degree in Nursing is required and Bachelors of Science in Nursing (BSN) is preferred - Minimum of five (5) years of clinical experience is required - Minimum of five (5) years of experience in one of the following is required: case management, utilization management, and/or quality improvement - Two years of utilization management experience is preferred - Managed care experience is preferred Competencies, Knowledge and Skills: - Beginning Excel, Word and PowerPoint experience - Experience in data analysis and trending - Knowledge of utilization management standards and practices - Communication skills - Management and prior supervisory skills - Ability to work independently and within a team environment - Attention to detail - Familiarity of the health care field - Critical listening and thinking skills - Training/teaching skills - Strategic management skills - Negotiation skills/experience - Proper grammar usage - Change resiliency - Technical writing skills - Time management skills - Proper phone etiquette - Customer service oriented - Decision making/problem solving skills - Leadership experience and skills Licensure and Certification: - Current, unrestricted licensure in state of practice as a Registered Nurse (RN) is required Working Conditions: - General office environment; may be required to sit or stand for extended periods of time Compensation Range: $83,000.00 - $132,800.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Salary Organization Level Competencies - Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business Brand=Commonwealth Care Alliance Originally posted on Himalayas
- Utilization-Management
- Case-Management
- Nursing-Management
- Quality-Improvement
- Utilization-Management-Manager
- Utilization-Management-Supervisor
- Utilization-Review-Manager
- Healthcare-Utilization-Manager
Наблюдалась 2026-10-10, впервые 2026-10-09, источник — Himalayas (JSON API).