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Overview

The Program Manager-Utilization Management (UM) will be accountable for the management, implementation, communication, and execution of the UM programs. They will be responsible for drafting, and/or identifying necessary changes in medical and administrative policy, including use and maintenance of MCG clinical criteria and the MCG Guideline Modification tool, all within the confines of regulations governing medical necessity criteria including but not limited to CMS, NCQA/URAC and New York State Insurance law. They will work through the process of obtaining approval for any changes from the Medical Director and governing committee(s) then overseeing the implementation throughout the organization (systemically, procedurally and communication). In addition, they will be responsible for identifying recommended changes to the UM Medical Management program and seeking approval from Medical Directors and Heathcare Service leadership to lead implementation throughout the organization which will include balancing the use of services on traditional UM pre-service, concurrent and retrospective review, services not currently on medical review as outlined by trend and cost containment activities, and services on automated UM review.

The Program Manager will ensure accurate implementation, system configuration and appropriate benefit administration of UM programs that demonstrate alignment between member contracts, regulatory requirements, provider reimbursement policies and medical policy. They will work collaboratively with and influence multiple departments to continually assess and make recommendations for improvements to maintain an effective and efficient utilization management process, as well as manage medical expenses based on trends. They will maintain UM review requirements, obtain reporting to understand utilization trends and cost, recommend changes to Healthcare Services Clinical and Operations leadership and ensure implementation of any changes approved. The Program Manager will be responsible for reporting, analyzing and communicating outcomes and recommendations, criteria revision, implementations and on savings opportunities and/or impacts from team activities to senior leadership.

Qualifications

• Bachelor's degree required. Master's degree preferred. An additional four (4) years of experience will be considered in lieu of degree.
• Five (5) years of experience in health plan managed care operations required; multi-dimension project management experience preferred.
• Registered Nurse (RN) with active, unrestricted NYS license strongly preferred.
• Certified Professional Coder (CPC) is strongly preferred.
• Knowledge of clinical care management processes, member benefit structures and applications, and claims processing.
• Knowledge of medical necessity criteria development, claims systems, clinical platforms and/or CRM applications.
• Prior experience with MCG and the MCG Modification tool functionality.
• Ability to define problems, analyze data/information and critically think through scenarios.
• Knowledge and experience in development of clinical processes and SOPs.
• Knowledge of ICD-10, CPT and HCPCS coding.
• Knowledge of program implementation with project management approach.
• Excellent verbal, written and interpersonal communications skills required with emphasis on diplomacy, negotiation, persuasiveness and interaction with multiple levels of management.
• Ability to work independently and lead or participate on multi-disciplinary project teams.
• Excellent time management and organizational skills.
• Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative and Accountable.

Essential Accountabilities

• Stay abreast of new clinical technology, treatments, testing and trends in the market to ensure medical and administrative policy is current and competitive within industry.
• Optimize existing policy as it relates to medical management and utilization management by monitoring what services require medical necessity review, and making changes (add/remove) as needed.
• Assess IH medical criteria vs MCG to define best practice use of criteria.
• Evaluate and maintain annual evaluation of all medical necessity criteria.
• Develop and maintain medical necessity criteria utilizing evidence-based literature and educate appropriate IH associates on the use and implementation of new criteria.
• Monitor utilization trends and clinical appropriateness and make changes (add/remove) in services or suppliers as needed related to effectiveness of the Gold Card and Post Service Pre-Payment (PSPP) programs.
• Develop and lead a cross-functional team (including Claims, IT, NCM, HCS, Servicing, and Product) to ensure consistent benefit interpretation across the organization.
• Oversee and ensure accurate system configuration and appropriate benefit administration to demonstrate alignment between member contracts, regulatory requirements, provider reimbursement policies and medical policies.
• Work collaboratively with multiple departments to continually assess and make recommendations for improvements to maintain an effective and efficient utilization management process and manage medical expenses based on trends.
• Analyze utilization trends and costs and communicate recommendations and potential savings/impacts to HCS leadership.
• Manage and support HCS team with regards to implementation and communication (internal and external) of new medical management processes.
• Work collaboratively with training resources to ensure all medical management staff are updated on new product changes and impacts to functions.
• Develop processes for the creation, tracking, and reporting of all benefit management changes within the medical management department.
• Maintain UM review requirements and ensure implementation of any approved changes.
• Maintain preventative list as designated by government entities.
• Assist in medical management policy and SOP development.
• Provide application systems expertise to client communities.
• Participate in the Provider Communications team and others as designated as the HCS department representative.

Immigration or work visa sponsorship will not be provided for this position

Hiring Compensation Range: $85,000 - $105,000 annually

Compensation may vary based on factors including but not limited to skills, education, location and experience.

In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off. The base salary range is subject to change and may be modified in the future.

As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant's race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law. Click here for additional EEO/AAP or Reasonable Accommodation information.

Current Associates must apply internally via the Job Hub app.