Req ID: 66912BR
This role is office based in Phoenix, AZ.
There is a potential for 0-10% travel to other Aetna health plans.
Oversight and Management of clinical utilization management audit team processes including the organization and development of high performing teams. Manager, Clinical Health Services is responsible for leading a team of clinical auditors who will be accountable for performing clinical audits of medical records submitted in support of precertification, concurrent review and clinical appeals submitted by providers. You must have the ability to have clinical judgment, utilization review, application of product benefits, understanding of regulatory requirements for Medicaid managed care and fraud and abuse, and verification of medical necessity utilizing nationally recognized criteria.
Fundamental Components included but are not limited to:
+ Reinforces clinical philosophy, programs, policies and procedures in development of audit review criteria and performance metrics for the utilization management audit team.
+ direction and communicates a business case for change by focusing on and addressing key priorities to achieve business results based on audit findings.
+ Identifies opportunities to implement best practice approaches and introduce innovations to better improve outcomes.
+ Accountable for meeting the operational and quality objectives of the unit, including day-to-day management of audit team for the appropriate implementation and adherence with established policies and procedures
+ Works closely with functional area managers to ensure consistency in clinical interventions supporting our plan sponsors.
+ Develop, initiate, monitor and communicate performance expectations.
+ Ongoing assessment for quality indicators and concerns
+ Recruitment and hiring process for staff using clearly defined requirements in terms of education, experience, technical and performance skills.
+ Assesses developmental needs and collaborates with others to identify and implement action plans that support the development of high performing teams.
+ Consistently demonstrates the ability to serve as a model change agent and lead change efforts.
+ Accountable for maintaining compliance with policies and procedures and implements them at the employee level.
+ Ability to evaluate and interpret data, identify areas of improvement, and focuses on interventions to improve utilization management review outcomes.
Qualifications Requirements and Preferences:
+ An active and good standing RN license is required
+ Bachelor's Degree in Nursing is preferred but not required
+ 1+ year of experience in a supervisory or management role for UM is required
+ 3+ years demonstrated staff management experience preferred
+ Excellent knowledge of health care industry required
+ Preferred industry depth in a Medicare and/or Medicaid line of business
+ Strategic thinking with proven ability to communicate a vision and drive results
+ Knowledge of Medicaid managed care utilization management operations and healthcare management required
+ Excellent interpersonal communication skills; ability to influence in executive settings required
+ Ability to optimize resources using excellent judgment, and an attitude that fosters teamwork and supports organizational goals
+ Strong team player and team building skills
+ Creative problem-solving skills
+ Proficiency with Microsoft Office applications (Outlook, Word, Excel, PowerPoint) required
Nursing - Registered Nurse
Clinical / Medical - Concurrent review / discharge planning, Clinical / Medical - Management: < 25 employees, Clinical / Medical - Precertification, Finance - Audit - operational controls
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft PowerPoint, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Visio, Desktop Tool - Microsoft Word
Benefits Management - Maximizing Healthcare Quality, General Business - Communicating for Impact, General Business - Maximizing Work Practices
Leadership - Driving Strategic and Organizational Agility, Service - Demonstrating Service Discipline, Service - Improving Constituent-Focused Processes
Benefit eligibility may vary by position.
Job Function: Healthcare
Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.
Associated topics: biomedical, drug development, food scientist, histology, immunoassay, kinesiology, nutritionist, patient, therapeutic, vaccine