Position Purpose:Supervise the daily operations of the Utilization Management (UM) department. Managing the states of IL,AL,PA,NC,MI,OH,TN,KY,DE.• Supervise the daily operations of the UM staff• Ensure appropriate usage of resources in order to facilitate the UM process• Ensure compliance within applicable state program guidelines• Evaluate compliance policies and procedures and analyze/recommend enhancements• Assist with ensuring consistent data collection from UM staff that is used to assist the company in achieving corporate goals, to improve monitoring and reporting in order to meet external requirements• Identify opportunities for process improvements necessary to facilitate department functions• Educate staff as necessary to ensure consistent performance and adhere to standards• Assist UM Manager and Director with coordinating and facilitating system processes with providers, partners, vendors, and subcontractors as necessary• For MCOs, supervise the Transition of Care staff and provide face to face contact with inpatient members at assigned hospitals.. Monitor programmatic budget and ensure compliance with spending guidelines

Develop and conduct clinical education courses, including Case management/InterQual education and training for new employees. Develop and maintain complex audit processes and audit tools related to authorizations, appeals, quality, case management, inter-rater reliability (IRR)and date entry.Audit established guidelines (e.g. InterQual) for medical necessity.Evaluate effectiveness of training programs including cost/benefit anyalses. Research,analyze, and recommend internal/external training programs.Assist With Policy and Procedure and/or work process development

Act as a liaison for all statewide appeals, fair hearings, review organizations and other external type appeals. Responsible for ensuring that all appeal letters generated comply with both State and NCQA requirements.Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of services requested. Coordinate with Medical Director(s) to clarify determinations or clinical rational.

Performs collaborative duties to assess and coordinate member care. Develop and implements comprehensive cost effective plans of care, educates members and their families abut service/requirement and ensures member involvement in the plan of care.Authorizes and coordinates referral for services. Ensures provider services are delivered without gaps and identifies functional deficiencies in plans of care.