St. Louis, MO
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Our client is currently seeking a talented person for a Director, Utilization Management position in Chesterfield, Missouri.
You will oversee operations of the referral management, telephonic utilization review, prior authorization functions, and case management programs. You will ensure compliance government and contractual guidelines and the mission, philosophy and objectives of Corporate and the health plan. You will also oversee the operations of the referral management, telephonic utilization review, prior authorization, and case management functions. You will support and perform case management, disease management and on site concurrent review functions as necessary. You will provide support to Provider Relations issues related to Utilization issues for hospitals and physician providers. You will coordinate efforts with the Member Services and Connections Departments to address members and providers issues and concerns in compliance with medical management requirements. You will maintain compliance with National Committee for Quality Assurance (NCQA) standards for utilization management functions for the prior authorization unit. You will develop, implement and maintain policies and procedures regarding the prior authorization function. You will also identify quality and risk management issues and facilitate the collection of information for quality improvement and reporting purposes. You will compile and review multiple reports for statistical and financial tracking purposes to identify utilization trends and assist in financial forecasting.
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