Manager, medical mgmtLegato Health Technologies

If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a `sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed. Responsible to manage a team of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources. Primary duties may include, but are not limited to: Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective. Areas managed may include authorizing inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Applies clinical knowledge to work with facilities and providers for care-coordination. May also manage appeals for services denied. Hires, trains, coaches, counsels, and evaluates performance of direct reports. Requires current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States, except in government business where it is preferred, and 5 years acute care clinical experience or any combination of education and experience, which would provide an equivalent background. Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. The following are level distinctions not required for posting. This level typically reflects a new manager, one managing a singular function, a manager with a smaller span of management, or one located in a unit where a higher level of management exists.For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Legato Health Technologies

Philippines
Permanent
Full-time