AmeriHealth Caritas Delaware is excited to have been chosen as one of the Medicaid managed care plans for the Diamond State Health Plan and Diamond State Health Plan- Plus programs. Backed by a national organization, we have long-term experience serving the Medicaid population in neighboring states. We are committed to delivering health care through innovative services and programs and are looking forward to helping Delaware become an even healthier state.
This position manages all elements of the Plan’s utilization management program and staff under the supervision of the Medical Director. This includes, but is not limited to functions related to prior authorization, medical necessity determinations, concurrent and retrospective reviews, and other clinical and medical management programs.
Direct activities of the Utilization Management staff. Oversee staff performance with regard to prior authorization, medical necessity determinations, concurrent review, retrospective review, continuity of care, care coordination, and other clinical and medical management programs. These responsibilities extend to physical and behavioral health care and transportation services.
Ensure effective daily operation of the Utilization Management Department utilizing all applicable statutory provisions, contracts and established policies and administrative procedures.
Maintain optimal staffing patterns based on contractual obligations and current Utilization Management budget. Comply with all policies and procedures for personnel requisitions, interviews and employment. Maintain accurate position control and organizational chats of assigned departments.
Prepare reports and conduct analysis of operations / services as required by departmental, corporate, regulatory, and State requirements. Work collaboratively with Information Services Department on identifying required data for reporting.
Assist in preparation, coordination, and follow up of Utilization Management audits, such as readiness review and OMPP site visits, pertaining to the Utilization Management Department.
Partner with community agencies and contracted vendors to develop and maintain collaborative contact to assure members have access to the appropriate resources and to avoid duplication of efforts.
Act as a liaison with outside entities, including but not limited to physicians, hospital, health care vendors. social services agencies, member advocates, OMPP and other similar entities.
Establish performance and productivity requirements and communicate expectations to management team. Work collaboratively with Supervisor in identification of individual and / or group deficiencies in scheduled Performances Reviews. Establish action plan for assessment and resolution of identified issues.
Comply with Corporate, Federal, and State confidentiality standards to ensure the appropriate protection of member identifiable health information
Current and unrestricted Registered Nurse licensure required.
Bachelor's Degree required.
3+ years in leadership role (Supervisor or above) within a utilization management department, preferably within a managed care organization.
3 to 5 years of relevant clinical practice within an acute care setting or managed care organization.
Demonstrated compentency utilizing healthcare data (e.g. developing/maintaining reports to facilitate change and/or increase productivity within the department.)
Demonstrated ability to develop/improve process improvement to achieve contractual compliance by collaborating with departments across an organization.
Successfully demonstrate the ability to communicate up and down layers of an organization.
Proficient in MS Office within a Windows-based environment, Citrix, JIVA, Streamline, and SharePoint. Familiartiy with Interqual criterion and electronic medical record and documentation programs.
Leaders in health care solutions for those most in need
AmeriHealth Caritas is the nation's leader in providing comprehensive health care solutions for those in most need and the chronically ill. We impact the lives of more than 5.7 million members nationwide. With more than 30 years of experience managing care for individuals and families in publicly-funded programs, we have become known for d...eveloping innovative solutions that help improve health outcomes while reducing costs.
Our mission, our goal
Our mission is to help people get care, stay well and build healthy communities. Our goal is to provide responsible managed care solutions, including Medicaid, Medicare, and CHIP - plus behavioral health, pharmacy benefits management and third-party management and administrative services.
Through outreach and grassroots advocacy, we develop a firm understanding of the unique health care needs of each community we serve. This allows us to customize our programs to best improve the health of those who call the community home.
At every step of the way, we make it a point to keep care at the heart of our work - just as we have for the past three decades.