Supervisor, Utilization Management

Imagine360 is seeking a Supervisor, Utilization Management to join the team! The Supervisor, Utilization Management is responsible for utilizing their nursing education, clinical, and professional experiences to provide supervision to the Utilization Management Nurses and associated programs and processes, as directed by the Senior Manager, Patient Review and Intake Services.

Position Location: 100% remote

Responsibilities include but are not limited to:

Collaborate with Senior Manager, Patient Review & Intake Services or Manager, Utilization Management to:

Manage team responsible for completing utilization management programs, processes, and tasks.

Edit, maintain, and implement policies & procedures that meet applicable regulatory, accreditation, and business needs.

Implement orientation curriculum and ongoing training and educational needs.

Coordinate and supervise daily employee activities through supervision of the UM team.

Maintain daily case assignment statistics and reporting for metrics.

Manage and coordinate daily & weekly staffing needs and schedules based on the business.

Review and manage approvals and communications for PTO requests by employees, as directed by the Manager or Senior Manager.

Conduct performance evaluations and performance improvement plans for team.

Conduct monthly 1:1 coaching sessions with UM Nurses, BR Nurses, and Lead Nurses.

Lead bi-monthly UM Nurse and Benefit Review Nurse meetings.

Lead the interviewing and hiring processes as needed.

Research member complaints and issue resolutions.

Lead projects and employee discussions that promote improvement in the delivery of services within the department.

Collaborate with Quality Management programs by assisting in the quality assurance review and chart audit processes for UM employees.

Perform monthly call and chart audits for the UM Nurses, BR Nurses, and Lead Nurses.

Review QA results to develop educational opportunities for the UM employees and completes performance improvement plans for scores <90% per policies and procedures.

Review policies and procedures as required and recommends changes to the Manager and Senior Manager.

Collect, analyze, and report data of quality improvement projects and other data related to utilization services and benefit review services.

Assist Supervisor, MIS with triaging of cases and monitoring call que as needed.

Escalate high priority, high risk cases or staffing issues appropriately to Manager or Senior Manager.

Perform UM tasks as staffing levels dictate.

Communicate effectively with members, employees, healthcare providers, vendors, peers, and customers.

Act as role model within a team setting to provide mentoring, coaching, and positive outcomes for employees, peers, and overall operations.

Attend team and department meetings, trainings, and other job specific events as required.

Adhere to established internal regulations regarding Department of Labor, HIPAA, ERISA and department and company policies and procedures.

Complete HIPAA training and trainings assigned by quality team monthly/annually; follow PHI guidelines.

Complete duties in accordance with scope of licensure and certifications held or requested.

Other duties as assigned by the Manager or Senior Manager.

Required Experience/Education:

• A nursing degree or diploma from an accredited college, university, or school of nursing
• Bachelor's degree in nursing preferred but not required.
• 3 years' experience in a clinical role with responsibilities for direct patient care.
• Experience in Utilization Review Services, Case Management, or transferable clinical experience and skills.
• Experience mentoring or managing a team of clinical or non-clinical staff.
• Experience working in a utilization review role.
• Experience working in a URAC accredited program preferred.
• Knowledge and ICD and CPT codes.
  
  
  

Skills and Abilities:

• Ability to work independently in a home office environment.
• Computer skills which include proficiency in Microsoft Outlook, Word, Excel, and PowerPoint, as well as navigation utilizing the internet.
• Ability to resolve problems independently and demonstrate ability to multi-task.
• Strong verbal and written communication skills.
• Strong presentation skills.
• Ability to demonstrate a commitment to building new skills and fostering a positive work environment.
  
  
  

License and Certifications:

• An active, current, and unrestricted Compact Registered Nurse License.
• Must maintain CEUs as required by applicable State Board(s) of Nursing and required certifications.
  
  
  

What can Imagine360 offer you?

• Multiple Health plan options
• Company paid employee premiums for disability and life insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Company paid Short & Long term Disability plus Life Insurance
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company's diversity and inclusion initiatives
  
  
  

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Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.

Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.

**RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/CV's submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation**