Responsibilities:

Under the supervision of the LTSS Manager for Utilization Management, the LTSS Supervisor UM Review—Clinical will oversee the work of the LTSS Review UM Nurses, LTSS Review UM Technicians and staff members within the LTSS Review Utilization Management Department. Responsibilities include providing clinical, technical and operational support and direction, including organization and monitoring of all LTSS services. Responsible for direct supervisory oversight of professional and front line staff receiving requests for authorizations from external customers which encompasses providers and members, as well as from the internal customers. Supervise staff to confirm that staff is able to assist and understand the member’s ongoing medical conditions, triage the members needs to the other appropriate specialty programs, and confirm that the plan of care prepared by the HCBS services coordinator reflects those medical needs.

• Assists with the daily operations of licensed and non-licensed professionals on the LTSS Utilization Management team.
• Monitors staff work assignments and makes appropriate adjustments based on staffing levels, staff experience, and number/request types of authorizations/appeals received.
• Provides coaching and counseling to improve productivity of staff members within Utilization Management.
• Assesses candidates and ensures that optimal qualifications are met as a member of the department’s interview team.
• Plans, develops and supports or conducts orientations, training programs and creates educational material for staff members to improve skills, aid in professional growth and development and to ensure staff’s expertise.
• Reviews quality audits and shares audit results in a timely manner with associates, providing necessary education and counseling to improve performance.
• Works collaboratively with the LTSS Manager of Utilization Management and identified leadership to develop and implement performance measures, and monitors associates placed on performance improvement plans.
• Responsible for writing and finalizing annual reviews for direct reports with Manager input.
• Participates in process reviews and the development of new and/or revised work processes, policies and procedures relating to Utilization Review.
• Accurately answers questions regarding Plan benefits for members and providers.
• Acts as a liaison with outsides entities, including, but not limited to, physicians, hospitals, health care vendors, social service agencies, member advocates, regulatory agencies.
• Creates and supports an environment that fosters teamwork, cooperation, respect, and diversity.
• Establishes and maintains positive communication and professional demeanor with internal and external customers, providers and members at all times.
• Stays current with ACFC policies and procedures and Medicare requirements
• Maintains operational processes, policies, procedures and reports to support LTSS care delivery
• May organize or lead rounds for selected members for MD review.

Education/Experience:

• Associate’s Degree.
• Bachelor’s Degree in Nursing.
• Unrestricted RN license.
• 3-5 years progressive experience in an acute care setting.
• Minimum 3 years of experience in managed care utilization review.
• Proficiency with Microsoft Office Suite (Word, Excel, Power Point). Access is a plus.
• Consistent word processing speed and accuracy of 50 or more words per minute.