VP – PHCO Utilization Management Medicaid & Marketplace

VP – PHCO Utilization Management Medicaid & Marketplace

Requirements

• Bachelor’s degree in Nursing, related field or equivalent experience
• 10+ years of nursing, utilization management, or case management experience in an acute care setting
• Experience in managed care environment
• Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff
• Current state’s nursing license

Responsibilities

• Oversee the operations of utilization management, reconciliation coordination, concurrent review (telephonic and on-site), specialty therapy programs and other related functions across multiple product lines in both centralized and multi-site regional environments
• Oversee the development and implementation of centralized and multi-site regional clinical and non-clinical training programs
• Provide strategic and tactical leadership and support to provider relations issues related to utilization issues for hospitals and physician providers
• Oversee coordination efforts with member services and the connections departments to address concerns regarding compliance with medical management requirements
• Maintain compliance with National Committee for Quality Assurance (NCQA) standards for utilization management functions, prior authorization and concurrent review units
• Collaborate with upper management to implement and maintain policies and procedures regarding the prior authorization and concurrent review functions across multiple product lines and overseen by multiple regulatory agencies
• Oversee processes used to assess quality and risk management issues and facilitate the collection of information for quality improvement and reporting purposes
• Review various reports for statistical and financial tracking purposes to identify utilization trends and assist in financial forecasting

Preferred Qualifications

No preferred qualifications provided.