Manager, Utilization Management Clinical Review

This position is responsible for the oversight of clinical review and the direction of UM staff to ensure productivity and quality standards are met at all times. The manager must have a comprehensive knowledge of all state and federal regulations in addition to accreditation standards related to UM and ensure compliance and maintenance of Medica's accreditation status and audit performance. The manager will also maintain confidentiality of all privileged information.

This role is critical to Medica and is also responsible for the improvement of UM and Clinical appeals processes through implementation, evaluation and intervention as well as the ability to identify strategic opportunities to improve broader Medica process issues and gaps. The manager understands, articulates, and supports the organization's mission, vision, goals and strategies.

The manager partners with internal and external stakeholders to develop and optimize interventions to facilitate and manage the utilization of health care services.

Qualifications

• Bachelors Degree in Nursing preferred, Associates Degree in Nursing required
• 5 years of clinical utilization and/or case management experience in either a payor or provider setting
• Experience in Utilization and/or Case Management

Required Licensure

• Current and unrestricted RN Licensure

Skills and Abilities

• Demonstrated leadership skills including excellent interpersonal communication skills, creative and innovative problem-solving ability, critical thinking and independent decision-making ability, group facilitation, negotiation, change management, conflict management skills and coaching skills
• Is a self-starter; can initiate project plans and actions once problem has been identified. Can act independently. Ability to drive a project forward in a matrixed organization
• Demonstrated process improvement and organizational skills
• Demonstrated ability to analyze data, conduct root cause analysis, solve multi-dimensional problems, implement necessary improvement plans and achieve business excellence through these efforts
• Experienced with Microsoft Office Suite
• Process improvement experience identifying and resolving complex issues, proven track record of accomplishing strategic goals and leading change
• Experience with implementing processes to support regulations, legislation, rules and/or laws and accreditation standards
• Experience with utilization management or case management tools (i.e. MCG/Interqual criteria), procedures and programs. Knowledge of utilization management criteria sets
• Experience working through issues/questions with regulatory and accrediting agencies, legal departments and staff
• Experience with data collection, assessment tools, reporting and analysis

This position is a Hub role, which requires an employee to occasionally come onsite to the designated office - Minnetonka, MN - for applicable heads-up work. Frequency is determined by business need as decided by leadership.

The full salary range for this position is $85,000 - $145,700. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to base compensation, this position may be eligible for incentive plan compensation in addition to base salary. Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

Medica's commitment to diversity, equity and inclusion (DEI) includes unifying our workforce through learning and development, recruitment and retention. We consistently communicate the importance of DEI, celebrate achievements, and seek out community partnerships and diverse suppliers that are representative of everyone in our community. We are developing sustainable programs and investing time, talent and resources to ensure that we are living our values. We are an Equal Opportunity/Affirmative Action employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.