Mgr Utilization Management RN

Get To Know Us!

WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans.

What is your impact?
The Manager of Utilization Management RN role supervises, and provides guidance to, designated clinical staff for Communitas Care Management team. This role acts as a team lead to the Utilization Management RNs.

What Will You Be Doing:

• Manage clinical staff and daily operations in designated clinical department including timekeeping, scheduling, staffing and managing POD meeting:
  
  
  
  • Responsible for initial problem-solving resource for clinical staff.
  • Responsible for daily evaluation of departmental reporting /needs and implement processes or staffing to support departmental requirements.
  • Requires daily evaluation/intervention of all clinical concerns and issues with rapid response.
  • Responsible for problem resolution with escalation to Sr. Manager as appropriate.
  • Provide clinical updates to Account Management and Stop Loss Carriers as requested.
  • Facilitates open and timely communication with clinical staff, departments, internal and external customers.
  
  
• Key responsibility for meeting URAC goals and objectives within the department.
  
  
  
  • Ensure adherence to SLA, TAT, NCQA, WebTPA policies, assist clinical staff with implementing process improvements, efficiencies, and meeting goals and objectives.
  • Assist clinical staff with implementing process improvements, efficiencies, and meeting goals and objectives.
  • Measure and monitor daily metrics with appropriate interventions.
  
  
• Assist with orientation and mentoring of new clinical staff and provides guidance to existing staff on complex issues.
• Reporting, recording, and monitoring productivity including measuring and monitoring daily metrics with appropriate interventions.
• Reporting to Sr. Management daily huddle and updates concerning staffing.

Qualifications:

• 5+ years combined work experience in Utilization Review and RN experience in a hospital setting.
• 2+ years direct supervisory/management experience
• Minimum Associate's degree in Nursing from an accredited school
• RN - Registered Nurse - Current Compact State Licensure
• Prior experience in utilization management or case management, preferably within the managed care environment.
• Assertiveness, self-motivation and a sense of responsibility are a must.
• Knowledgeable in medical terminology, reasonable and necessary treatment plans, delivery quality health care services and cost containment practices.
• Ability to work effectively with all levels within the organization from staff level to management team; ability to collaborate with cross-operational areas within the organization.
• Adherence to ethical, legal and accreditation/regulatory standards.

Preferred Qualifications:

• Knowledge of managed care in a self-funded employer population.
• Previous experience with URAC accreditation preferred.

What We Can Offer YOU!

To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to:

• Medical, dental, vision, life and global travel health insurance
• Income protection benefits: life insurance, Short- and long-term disability programs
• Leave programs to support personal circumstances.
• Retirement Savings Plan includes employer contribution and employer match
• Paid time off, volunteer time off, and 11 holidays
• Additional voluntary benefits available and a comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for interns and part-time employees may differ.

General Physical Demands:

Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.