The Supervisor, Medical Management supervises and supports the Director of Medical Management in their vision for the Utilization and Case Management Departments, including planning, organizing, and coordinating the activities of the Utilization Management and Case Management programs. Requirements include working knowledge of the managed care environment, TRICARE, DoD, Utilization Management and Case Management standards and programs, and USFHP Policies and Procedures. This position includes daily clinical discretionary capacity that has potential to affect the financial well-being of the health plan.
Responsible for all supervisor aspects of the Medical Management department (Case Management/Utilization Management), including:
Supervise the selection, training, development, appraisal, and work assignments, staffing and productivity of Associates within Medical Management.
Ensures appropriate application of existing review criteria (MCG) in the Utilization Review Process.
Supervises daily activities of Medical Management clinical staff, individually and as a team to ensure the following objectives are met:
Collaborates with the Director of Medical Management and the Medical Director to facilitate provision of services throughout the health care continuum and participates in Health Plan related initiatives.
Identify and refer quality issues to the Director of Medical Management or Medical Director.
Provides supervision and clinical leadership to Medical Management staff.
Supervises utilization management activity and referrals to the Medical Director.
Supervises case management and disease management referral activity from utilization management.
Maintains appropriate staffing ratios and team assignments based on volumes.
Perform utilization review of inpatient admissions, and outpatient surgeries, as necessary to ensure turnaround times and processing times are met.
Assists the Medical Management Director with supervisory duties including, but not limited to, work assignments, quality and audit reviews.
Conducts reliability audits of the internal review process to monitor compliance with performance standards and submits to the Director of Medical Management to develop action plans to address areas needing improvement.
Provides assistance with emergency calls that may affect consumer safety.
Collaborate with Claims, Quality Management and Provider Relations Departments as requested.
Participates in work groups and committees oriented toward improving health plan operations
Responsible for development and maintenance of policies and procedures for department.
Responsible for HIPAA and Integrity compliance within department
Responsible for ensuring staff compliance with URAC/NCQA requirements
In the absence of the Director of Medical Management conducts morning rounds
Works closely with department Director to identify and plan for opportunities for improvement within areas of responsibility
Collaborate with and maintain open communication with all departments within CHRISTUS Health and US Family Health Plan to ensure effective and efficient workflow
Graduate of an accredited Registered Nursing program
Bachelor Degree In Nursing , Preferred
Excellent computer skills needed
Experience with Clinical Decision Support tools (i.e.: MCG)
Experience with word processing/spreadsheets including Excel.
Excellent verbal and written skills
Minimum of five to seven years clinical experience
Minimum of one year of management experience
Three to five years Utilization Management/Case Management experience
Minimum of one year of Health Plan experience
Experience with audits and regulatory agencies mandatory
B. Licenses, Registrations, or Certifications:
Current/Active unencumbered Texas RN licensure
Eligibility for Louisiana RN licensure (obtained within 6 months of employment)
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.