Mgr Utilization Management RN (Remote)

Get To Know Us!

WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans.

What is your impact?

This position supervises, and provides guidance to, designated clinical staff for Communitas Care Management. Acts as a team lead to the Utilization Management RNs.

What Will You Be Doing:

The essential functions listed represent the major duties of this role, additional duties may be assigned.

• Manage clinical staff and daily operations in designated clinical department including timekeeping, scheduling, staffing and managing POD meeting.
• Responsible for initial problem-solving resource for clinical staff. (30%)
• Responsible for daily evaluation of departmental reporting /needs and implement processes or staffing to support departmental requirements.
• Requires daily evaluation/intervention of all clinical concerns and issues with rapid response.
• Responsible for problem resolution with escalation to Sr. Manager as appropriate.
• Provide clinical updates to Account Management and Stop Loss Carriers as requested.
• Facilitates open and timely communication with clinical staff, departments, internal and external customers.
• Key responsibility for meeting URAC goals and objectives within the department. (20%)
• Ensure adherence to SLA, TAT, NCQA, WebTPA policies, assist clinical staff with implementing process improvements, efficiencies, and meeting goals and objectives.
• Assist clinical staff with implementing process improvements, efficiencies, and meeting goals and objectives.
• Measure and monitor daily metrics with appropriate interventions.
• Assist with orientation and mentoring of new clinical staff, and provides guidance to existing staff on complex issues. (20%)
• Reporting, recording, and monitoring productivity including measuring and monitoring daily metrics with appropriate interventions. (20%)
• Reporting to Sr. Management daily huddle and updates concerning staffing. (10%)

Qualifications

• 5+ years related work experience.
• Experience Details: Utilization review, RN experience in a hospital setting and professional background in clinical nursing and patient assessment.
• 2+ years direct supervisory/management experience
• Related Bachelor's degree or additional related equivalent work experience
• Minimum associate's degree in nursing with 2 years of medical management experience.
• RN - Registered Nurse - State Licensure And/or Compact State Licensure RN license, requiring graduation from an accredited school of nursing and must hold current state RN licensure; Multistate license required if living in a nurse compact state
• Prior experience in utilization management or case management, preferably within the managed care environment.
• Assertiveness, self-motivation and a sense of responsibility are a must.
• Knowledgeable in medical terminology, reasonable and necessary treatment plans, delivery quality health care services and cost containment practices.
• Knowledge of medical terminology, reasonable and necessary treatment plans, delivery of quality healthcare services and cost containment practices.
• Ability to work effectively with all levels within the organization from staff level to management team; ability to collaborate with cross-operational areas within the organization.
• Good verbal and written communication skills.
• Maintaining client's privacy, confidentiality and safety as well as acting as an advocate for the covered member.
• Adherence to ethical, legal and accreditation/regulatory standards.

Preferred Qualifications

• Knowledge of managed care in a self-funded employer population.
• Previous experience with URAC accreditation preferred.

What We Can Offer YOU!

To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to:

• Medical, dental, vision, life and global travel health insurance
• Income protection benefits: life insurance, short- and long-term disability programs
• Leave programs to support personal circumstances.
• Retirement Savings Plan includes employer contribution and employer match
• Paid time off, volunteer time off, and 11 holidays
• Additional voluntary benefits available and a comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for interns and part-time employees may differ.

General Physical Demands

Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

Physical/Environmental Activities

Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Occasionally

We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.