Director, Clinical Utilization Management (RN)

  • 16945 Northchase Dr, Houston, TX 77060, USA
  • Full-time

Company Description

WNS Global Services Inc. (NYSE: WNS) is a global Business Process Management (BPM) leader. WNS offers business value to 400+global clients by combining operational excellence with deep domain expertise in key industry verticals, including Banking and Financial Services, Consulting and Professional Services, Healthcare, Insurance, Manufacturing, Retail and Consumer Packaged Goods, Shipping and Logistics, Telecommunications, Travel and Utilities. Globally, the group’s over 44,000+ Professionals serve across 60 delivery centers in 16 countries worldwide.

WNS Philippines - Established in 2008, WNS Philippines has been delivering the full spectrum of BPM services – in customer interaction services, finance and accounting, research and analytics, technology solutions and industry-specific businesses for more than 10 years. With more than 8,000 employees spread across 11 sites located in 4 key cities, Quezon City, Pasig City, Muntinlupa City, and Iloilo City – WNS is one of the fastest growing centers in the country.

Why Join Us?

At WNS, our mission is to enable clients to outperform with our passion for service and innovation. At the heart of each client engagement is our pursuit to understand our client’s business, and create impactful solutions that can drive agility and excellence into their business processes. Our promise of outperformance stems from our deep domain expertise, partnership approach and a global delivery network.

Our mission as an organization is guided by our CIRCLE of values: Client First, Integrity, Respect, Collaboration, Learning, Excellence.

We promise our employees to experience role clarity, coaching and mentoring, professional development and structured career path through our 5 people promises and keeping employee experience at the core. Experience the culture of outperformance, engagement, celebration and enjoy wide variety of best in class benefits including free HMO coverage for self and dependent from Day 1; Also contribute to society through our WNS Cares Foundation, where you have the opportunity to support meaningful initiatives and make an impact in the community.

Job Description

·          Enables supervisors and team members to ensure consistent quality service to provider and members

·          Communicates with supervisors, employees and customers to ensure prompt and courteous attention to all questions regarding products and services

·          Responsible for knowing the intricacies and compliance standards of all key programs and contracts

·          Refers all complaints to director of compliance, works collaboratively with the compliance department to investigate complaints and correct errors

·          Handles and reviews disciplinary actions directly with employees, i.e., verbal warnings, records of discussion, and formal disciplinary documentation. Collaborates with Human Resources to ensure adherence to company policies

·          Continuously coach the team to ensure the individual and team performance goals are achieved

·          Partners with Workforce Planning to ensure appropriate resources are allocated to meet workload demand

·          Monitors staff work assignments and coordinates with clinical management team to make appropriate adjustments based on staffing levels, proficiency, types of request, and amount of cases received

·          Serves as first point of escalation for procedural and technical issues and coach staff regarding how to effectively resolve the issue(s)

·          Tracks and monitors team performance; provides feedback

·          Conducts formal performance appraisals of direct reports and prepares and communicates performance reviews and development recommendations

·          Assists with service restoration efforts during emergencies

·          Supervises a team of clinical staff with varying professional license and education levels

·          Serves as an additional training resource to the clinical review team

·          Accurately answers questions regarding Plan benefits for members and providers

·          Develops and implements process improvements to increase operational efficiencies

·          Promotes business focus which demonstrates an understanding to the company’s vision, mission, and strategy

·          Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others

·          Utilizes knowledge of telephony, ACD, workforce, and related systems to manage daily phone metrics

·          Performs other related duties and projects as assigned

·          Participates in the HealthHelp Quality Management Program as required

·          Adheres to all HIPAA, state and federal regulations pertaining to the clinical programs

·          Adheres to both URAC & NCQA standards pertinent to their job description

 

Qualifications

·          Graduate of an accredited school of nursing

·          Current active unrestricted RN license required

·          Bachelor’s degree in a health related field required; Masters preferred

·          5-10 years acute care experience

·          Minimum 5 years experience in UM managed care setting required

·          Minimum 5 years experience in utilization management preferred

·          Minimum 5 years of progressively responsible supervisory experience in a managed care environment preferred

·          Strong interpersonal skills at both individual and team level

·          Excellent oral and written skills

·          Proficient leadership and facilitation skills

·          Ability to utilize critical thinking skills

·          Excellent organizational skills

·          Ability to work in a fast-paced evolving environment, on-call after hours work may be required

·          Highly motivated, self-starter who works independently using all available resources, policies, and procedures to work effectively and meet deadlines in an atmosphere of multiple projects and shifting priorities

·          Demonstrated leadership and facilitation skills

·          Demonstrated knowledge and experience in using critical thinking skills

·          Experience in team interactions and improvement methods/projects (e.g., coaching quality and productivity)

·          Knowledge of Microsoft Office and programs including Outlook, PowerPoint, Excel, Word and Visio

Additional Information

All your information will be kept confidential according to EEO guidelines.

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