Clinical Operations, Leader, Behavioral Health Utilization Management
Status: Full-time, Exempt: Yes
This role oversees the development, implementation, ongoing operations, assessment and monitoring of MVP Utilization Management programs. Residency in NY is mandatory. Related responsibilities
include but are not limited to:
Responsible for the Clinical Care Management System updates and training.
Analyzes and reports significant utilization trends, and patterns to appropriate departmental and medical staff committees.
Hires, coaches, trains, and manages staff to ensure effective outcomes in BH utilization management.
Facilitates educational training and oversees inter rater reliability for clinical staff on issues related to utilization management.
Supports Integrated Health model development across all UM activities.
Assures compliance w/ Federal, State, NCQA, other regulatory agencies, and internal standards and requirements. Keeps current on all state and federal regulations affecting UM activities. Monitors UM standards at the state and national level to ensure that MVP remains at the forefront of compliant and effective member focused UM.
Supports and develops state-of-the-art utilization management programs, including
precertification, concurrent review, prior authorization, retrospective review and out of network clinical editing.
Actively participates in leadership/management activities to help identify internal and
external challenges and opportunities. Contributes to sound organizational strategies and actions; and provides insight, feedback, and counsel to other members of the Management team.
Works with BH Senior Leadership to determine departmental goals and to plan short-
and long-term strategies to meet corporate goals.
Acts as the liaison for Utilization Management on the Medical Management and Quality Improvement committees.
Completes other duties regarding Utilization Management functions as assigned.
R.N. or L.C. S.W. with active license in New York required;
Masters’ degree in Nursing, Business or other related area strongly preferred.
Ten (10) or more years of experience in utilization management within a health
plan. Hospital or another UM experience considered.
Leadership skills including people management experience and demonstrated effectiveness in influencing and managing professional staff.
Regulatory or accreditation audit experience
Experience in medical cost management strategic plan development and execution
Knowledge of NYS child serving systems required.
Experience in integrated health delivery (physical and behavioral health) a strong plus
Experience working with community and family-based services recommended
Leadership skills including people management experience and demonstrated effectiveness in influencing and managing professional staff
Superior communication skills
Superior priority setting and time management abilities
Strong data, system and computer skills
Demonstrated knowledge of operations and healthcare management; NCQA, CMS, and other local, state, and federal regulations
Knowledge of managed care operations, process improvement and techniques
Knowledge of BH rehabilitation and recovery services.
Independent thought process; oriented toward probing and problem solving
MVP Health Care is an Affirmative Action/Equal Opportunity Employer (PDF). We recruit, employ, train, compensate, and promote without regard to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, disability, genetic information, veteran status, or any other basis, e.g., Pay Transparency (PDF), protected by applicable federal, state or local law. Any person with a disability needing special accommodations to the application process, please contact Human Resources at firstname.lastname@example.org.
- Job Family Medical Management/Clinical
- Pay Type Salary
- Headquarters Office, Schenectady, New York, United States of America
- Rochester Office, Rochester, New York, United States of America
- Tarrytown Office, Tarrytown, New York, United States of America