Director, Clinical Utilization Management (RN)

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

Company Description

HealthHelp - A WNS Company (www.HealthHelp.com), is the leader in the field of healthcare utilization & care management. We have gained this position by actively working to change out-of-date practices with a collaborative, non-denial based approach. Our methodology helps payors achieve a higher return on investment, gives providers education programs that better inform physicians, and ensures quality and safety for the patients needing treatment.

HealthHelp’s innovative approach and strong IT capability in specialty benefits management means that staff will move healthcare forward when provided with evidence-based solutions and second opinions. HealthHelp's staff is comprised of healthcare professionals who make a difference every day. HealthHelp has a desire to fill their company with talented and innovative people who want a career path filled with success and personal growth.

Our specialty benefits management services are broad and include, Cardiology, Oncology, Radiology, Radiation Therapy, Sleep Care, and Musculoskeletal Care. HealthHelp has two locations in Houston, one a corporate office and the second a state-of-the art contact center. HealthHelp is also proud to have another such contact center in Albany, New York.

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.

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

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