Manager Government Utilization Management

To learn more about Arkansas Blue Cross and Blue Shield Hiring Policies, please click here.Applicants must be eligible to begin work on the date of hire. Applicants must be currently authorized to work in the United States on a full-time basis. ARKANSAS BLUE CROSS BLUE SHIELD will NOT sponsor applicants for work visas in this position.Arkansas Blue Cross is only seeking applicants for remote positions from the following states:Arkansas, Florida, Georgia, Illinois, Kansas, Louisiana, Minnesota, Mississippi, Oklahoma, South Carolina, Tennessee, Texas, Virginia and Wisconsin.

Job SummaryThe Manager Government Utilization Management is responsible for the clinical review of all lines of business for government plans prior to, and during inpatient adminssions, and outpatient procedures. The role evaluates the efficiency and appropriateness for inpatient stays and outpatient procedures for medical necessity through review with evidence-based criteria of cliincal guidelines and policies. The incumbent promotes quality toward cost effective outcomes based on evidence. Incumbent serves as a consultant to less skilled nurses to review and/or collaborate when review determination cannot be met based on initial clincal review.Requirements

EDUCATION

BSN degree in nursing preferred; MSN preferred. Related health degree will be considered along with appropriate, active RN license as stated below.

CERTIFICATIONS & LICENSES

Registered Nurse (RN) license, active and unencumbered state license in the state where job duties are performed is required

EXPERIENCE

Seven (7) years' clinical practice nursing experience in at least one of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing (With Masters' degree, five (5) years' practice nursing experience as described above will be considered.)

Five (5) years' leadership experience (role, project management, team leader, etc.)

Minimum four (4) years' experience working in utilization management including inpatient, outpatient, and post service prepay

Minimum three (3) years'' experience and knowledge of health care regulations, compliance requirements and guidelines specifically related to government programs

Demonstrated experience working in government business such as Medicare managed care, including regulatory and compliance requirements or Medicaid government product strongly preferred

Experience with MCG Care Guidelines and InterQual knowledge of IPUM and OPUM

Experience working with and managing Local and National Coverage Determinations

SPECIALIZED SKILLS & ABILITIES

Ability to work with physicians and other professionals to develop improved utilization of effective and appropriate services

Excellent verbal and written communication skills with providers, members, and internal stakeholders

Demonstrated ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others

Proficiency in software applications that include, but are not limited to, Microsoft Suite Applications, electronic medical records, and other health care management systems.

Ability to work with minimal guidance; seeks guidance on only the most complex tasks

Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action

Strong analytic skills to assess utilization data identify trends and develop strategies to improve efficiencies and effectiveness.

Advanced interpersonal (e.g., mediating, counseling, mentoring, influencing), negotiating and management skills required to manage effectively

SkillsResponsibilitiesAdheres to URAC Standards and state mandates for all states represented by members as well as federal regulations for all utilization management reviews, Collaborates with other teams within the Medical Management Area, Customer Service and Claims Processing areas for all government plan lines of business, Corporate Medical Director, legal team, and case managers within the Enterprise, Communicates directly with internal and external physicians and facilities, providers/designees for the medical necessity of healthcare services, Cooperates and workds effectively with all department and division staff to facilitate services to m embers and providers of care, Facilitates appropriate cost-effective and cost-containment measures, Makes decisions based on facts and evidence assuming responsibiltiy for those decisions, Manages the hiring, coaching/training, employee development and performance management of assigned team, Monitors cases for medical necessity, quality of care, and level of care, Participates in continuous quality improvement activities, Practices utilization management activities within the scope of practice, Remains current with medical and surgical procedures, products, and general trends in health care delivery, Remains current with ongoing changes in medical practice by use of evidence-based guidelines and medical policy, Serves as a consultant to less trained nurses to review and/or collaborate when review determination cannot be met based on initial clincial review, Serves as a resource for non-clinical staff, Works incoming and assigned outbound calls to/from providers and facilities dailyCertificationsSecurity Requirements

This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties

Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

Employment TypeRegular

ADA Requirements

1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment