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Supervisor, Utilization Management

Company: Cambia Health Solutions
Location: Burlington
Posted on: June 6, 2021

Job Description:

Supervisor Utilization Management Remote from WA, OR, UT, ID

The Supervisor Utilization Management supervises the team and acts as a resource for utilization management professional and support staff. Oversees and coordinates team activities to achieve business objectives and ensure medically necessary, cost-effective, quality care is delivered to members through various utilization management programs, including prior authorization and inpatient concurrent review, and regulatory compliance. May also be responsible for ensuring that medical payments are appropriate and in alignment with contract provisions, proper coding and policy compliance.


* Assigns and prioritizes work, sets goals, and coordinates daily activities of the team. Provides regular updates and communication to staff through 1:1 and team meetings. * Monitors individual and team results to ensure work is completed in a timely manner, in accordance with department standards and procedures, and is in compliance with medical policy and medical necessity guidelines. * Assists in development of productivity and quality standards. May conduct or participate in compliance audits and report audit findings. Identifies and implements process improvements as needed. * Acts as a resource for staff and others. Appropriately escalates issues and partners with other departments to resolve issues and remove barriers. Collaborates with physician advisors on complex case and coverage determination processes. * Participates in the hiring process, provides on-going coaching, employee development and writing of performance reviews. Develops and maintains desk reference guides on work procedures. Ensures new hires complete necessary training. Assesses training needs and plays an active role in development of staff. * Completes special projects as assigned and may provide back-up support to staff as needed. * Maintains clinical competency and keeps current on medical practices, procedures and industry trends. * May develop and present educational updates to other departments. * May develop and present educational updates internally or to other departments. * Seeks ideas and opportunities for continuous improvement, determines which opportunities should be pursued and implements improvements as appropriate.

Minimum Requirements

* Demonstrated competency in setting priorities for a team and overseeing work outputs and timelines. * Ability to communicate effectively, verbally and in writing including with members, employer or provider groups. * Ability to effectively develop and lead a team (including employees who may be in multiple locations or work remotely). * Demonstrated experience in recognizing problems and effectively resolving complex issues. * Familiarity with health insurance industry trends and technology. * Demonstrated competency related to clinical utilization management and care management practices. * Ability to apply best practices and designated standards. * Knowledge of payment coding guidelines, as applicable (Payment Review only). Normally to be proficient in the competencies listed above

A Supervisor of Utilization Management would have a bachelor's degree in Nursing or related field and 3 years of leadership experience and 5 years of clinical experience or equivalent combination of education and experience.

Required Licenses, Certifications, Registration, Etc.

Must have a current unrestricted Registered Nurse (RN) license and at least three years full time equivalent direct clinical care.

Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. Regence is 2.2 million members, here for our families, co-workers an To view the full job description, click here

Keywords: Cambia Health Solutions, Bellingham , Supervisor, Utilization Management, Other , Burlington, Washington

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