• Manager of Utilization Management- Medicare

    Job Location US-MI-Detroit
    Job ID
    Utilization Management
    Business Line
    CMC Corporate
  • Overview

    Who we are:

    Meridian, a WellCare Company, is part of a national network of passionate leaders, achievers, and innovators dedicated to making a difference in the lives of our members, our providers and in the healthcare industry.


    We provide government-based health plans (Medicare, Medicaid, and the Health Insurance Marketplace) in Michigan, Illinois, Indiana, and Ohio. As a part of the WellCare Family of companies, we deliver healthcare excellence to millions of members nationwide.


    Our associates work hard, play hard, and give back. Meridian associates enjoy an exceptional experience and culture including special events, company sports teams, potlucks, Bagel Fridays, and volunteer opportunities.


    A Day in the Life of a Manager of Utilization Management - Medicare:

    This position is responsible for the daily operational management and supervision of the utilization review functions within the Utilization Management – Medicare Department. This position includes the responsibility for providing overall direction, education, orientation, coordination and evaluation of the,  Utilization Management Operational Leads, Transitional Care Coordinators, Transplant Care Coordinators, Inpatient Review Nurses, Preservice Nurses, Behavioral Health nurse, Denial staff, Utilization Management Care Coordinators and all other Utilization Management Medicare staff  to optimize workload and outcomes, maintain all regulatory and accreditation requirements and function cross-departmentally in the coordination of member care.


    • Directly manage all Utilization Management- Medicare staff including, but not limited to, hiring, training, scheduling, monitoring workload, conflict resolution, conducting performance evaluations and implementing performance improvement and disciplinary actions, when necessary
    • Provides oversight in the development and implementation of orientation and training activities for Utilization Management – Medicare
    • Oversee workload needs on a concurrent basis including monitoring phone coverage and clinical work queues in the department and weekly production reports.  Daily prioritization of staffing assignments for optimizing impact on department production
    • In conjunction with the Nurse Educator reviews inter-rater reliability tests and audits among Utilization Management Care Coordinators.  Evaluates the consistency of utilization management decision making based on MHP, InterQual Medicare, CMS and state specific Medicare criteria and acts on opportunities to improve consistency when applicable
    • Act as the primary resource in cooperation with the Medical Director and Vice President of Medicare for benefit interpretation including the consistent application of procedural practices established by MHP, Medicare, and state specific Medicaid guidelines
    • Provides for ongoing training and education to the staff through one-on-one, classroom settings and web based programs in regards to regulatory and accreditation requirements, and other necessary job-related skills
    • Identify, Implement and Evaluate process improvement activities
    • Provide on-going coaching and counseling of all staff
    • Promote the professional development of all staff
    • Oversee the collection of Healthcare Effectiveness Data Information Set (HEDIS) information as is applicable to the differing job functions
    • Actively participates in the Hospital Care Coordination weekly meetings by providing education and direction to the staff
    • Oversees the coordination of care of potential transplant members including obtaining all necessary clinical information to determine appropriateness and medical necessity of transplant, presentation of case to medical director for approval, coordination of care for member across the continuum by appropriate case management referrals, obtaining clinical updates and reviews as needed, and submitting the appropriate information to finance, claims and the re-insurer.  Work with Provider Services for contract negotiation when necessary
    • Solve utilization issues that occur by acting as the primary resolution point of contact.  Utilize professional knowledge, MHP knowledge and pertinent resources or use the appropriate reporting structure to solve problems and issues as identified
    • Maintain strict confidentiality of employee and organizational information in accordance with MHP, HIPAA and State privacy regulations
    • Performs other job functions as requested by the Vice President and Director of Utilization Management


    What you can bring to Meridian:

    • Bachelor’s degree is required
    • Three to five years of experience, education and/or certifications in utilization management, case management or other appropriate health care specialty is required
    • A minimum of four years of progressive management experience is preferred
    • Knowledge of MHP’s mission and operational structure
    • Knowledge of managed care, particularly utilization management processes
    • Knowledge of Medicare guidelines, medical necessity and benefit structure
    • Knowledge of National Committee for Quality Assurance (NCQA), CMS, State regulations, URAC or general accreditation requirements and guidelines for utilization management, denials and appeals
    • Demonstrated leadership skills
    • Organizational skills
    • Excellent written and verbal communication skills
    • Demonstrated clinical knowledge and expertise
    • Ability to prioritize work load
    • Ability to work as part of a team while meeting individual goals and objectives
    • Ability to identify, develop and implement process improvements


    What Meridian can offer you:

    • Our healthcare benefits include a variety of plans that are effective on the first day of employment for our new full-time team members.
    • Opportunity to work with the industry’s leading technologies and participate in unique projects, demonstrations, conferences, and exclusive learning opportunities.
    • Meridian offers 401k matching that is above the national average.
    • Full-time Meridian employees are eligible for tuition reimbursement towards Bachelor’s or Master’s degrees.
    • Meridian was named Detroit's #1 Fastest Growing Company by Crain's Magazine, so it is a great time to get involved with Meridian.


    Equal Opportunity Employer



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