Utilization Management Team Lead

Quality Assurance Park Ridge, Illinois


Description

Position at Clear Spring Health

Group1001 is a consumer-centric, technology-driven family of insurance companies on a mission to deliver outstanding value and operational performance by combining financial strength and stability with deep insurance expertise and a can-do culture. Group1001’s culture emphasizes the importance of collaboration, communication, core business focus, risk management, and striving for outcomes. This goal extends to how we hire and onboard our most valuable assets – our employees.

Utilization Management Team Lead

Location: Park Ridge, IL 

Company Overview:

Clear Spring Health is part of Group One Thousand One (“Group1001”), a customer-centric insurance group whose mission is to make insurance more useful, intuitive and accessible so that everyone feels empowered to achieve financial security.  Clear Spring Health is dedicated to helping seniors protect their health and well-being by providing Medicare Advantage plans in select counties of Colorado, Illinois, North Carolina, and Virginia, plus Georgia and South Carolina.  In addition, Clear Spring Health sponsors Medicare Prescription Drug plans in 42 states.

Job Summary:

Under the direction of the VP of Health Care Services, develops, coordinates and manages the administrative and operational activities that are directly associated with the utilization management of medical services provided to CCAI members. Manages and supervises the Utilization Management Nurses and other staff as assigned, ensures that review requests are performed using nationally recognized guidelines such as Milliman Guidelines. Provides leadership in Health Care Services programs, operations, projects, policies and procedures to ensure high quality results. Works independently; establishes priorities for staff.

Main Accountabilities:

  • Evaluates CCAI staffing levels to ensure maximum efficiency.
  • Manages and resolves human resource, employee, department safety, and risk management issues. Responsible for all aspects of staff management including, hiring, development/training, performance reviews and terminations.
  • Reports regularly and timely to the VP of Health Care Services any issues regarding areas of supervision.
  • Develops and implements policies to reinforce high quality, efficient workflows.
  • Ensures that review requests are performed using nationally recognized and evidence-based standards such as Milliman Guidelines, with duties including but not limited to: Ensures that the Milliman Guidelines or other criteria adopted by CCAI are used appropriately when applied to prior authorization requests.
  • Ensures that staff maintains current knowledge of Milliman Guidelines or other criteria adopted by the health plan;
  • Ensures that authorizations are entered into CCAI system in a timely fashion and within mandated timeframes
  • Ensures quality of documentation.
  • Provides prior authorization, discharge planning and transition of care coverage in the event of staffing shortfalls.
  • Ensures that members are notified of any denials in a timely and culturally competent manner in accordance with contractual mandates and accreditation standards.
  • Ensures that members are notified of appeal rights.
  • Investigates and follows up on complaints, grievances and quality issues related to CCAI utilization management functions.
  • Participates as a team member in all CCAI Utilization Management Department trainings, activities, and projects.
  • Maintains current knowledge of benefits and benefits changes.
  • Assists the VP of Health Care Services in preparation for audits and other regulatory issues.
  • Actively participates in the Health Care Services Leadership Team.

Qualifications:

  • Licensed Registered Nurse.
  • 3-5 years Managed Care experience in Utilization Management.
  • Working knowledge of Medicare Advantage plans.
  • 2-3 years of management experience required.
  • Strong analytical skills.
  • Strong computer skills – Microsoft Office Suite.
  • Strong communication and interpersonal skills.