Utlization Review Supervisor: AvMed Health Plans

Position Summary:

To support the Management of Utilization Management to achieve clinical and service driven objectives by assisting in coordination of care issues for our members. Assist with the management of the Utilization Management Program ensuring objectives and goals of the department are carried out to achieve the desired outcomes. Effective management of the Inpatient census and plan of care for all members in addition to knowledge of all Coordination of Benefits, Never Events, QI’s and possible cases for targets and interventions. Focused reviews and collaboration on the Top 30 hospitals statewide and other facilities as needed. Focus on all Re-admission cases for prevention and coordination of services to prevent future readmissions to the acute setting. Day-to-day oversight and accountability for inpatient utilization for assigned Plan areas. Act as a liaison between the Utilization Management staff, UM Manager, and Medical Directors in reporting, identifying specific problems, and offering strategic ideas for improvement regarding the Utilization Management Program. Work closely with the Medical Support Service department to reflect UM Compliance on UM issues and the denial process. Provide coverage for UM nursing staff and Management as needed. Coordinate report from the Inpatient Case Managers regarding clinical updates and plan of care for discussion with Medical Director, Director of Care Management, and/or UM Manager. Participates in the interviewing process to assess qualification and feedback for tentative new staff members for the UM department focusing on core values of the company. Take granular accountability for every case that is in an inpatient/obs status which is inclusive of asking the Inpatient Case Managers granular questions such as plan of care, Milliman variance, alt setting, mechanism of injury, as applicable clinical and administrative questions (when appropriate).

Education/Experience Requirements:

Registered Nurse with a current Florida license. Supervisory or management experience in a managed health care setting. Five years of acute clinical/surgical experience, current experience in Utilization Management to include Pre-Authorization, Utilization Review, Concurrent Review, Discharge Planning, Skilled Nursing Facility reviews and Complex Case Management. Three to five years of previous HMO experience.

AvMed Health Plans is a Drug/Tobacco-Free Workplace, EOE.