um ManagerGenfinity

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Utilization Management Manager (Philippines)
Position Summary
The Manager, Utilization Management leads a team of clinicians to effectively meet the client requirements for completion of all daily utilization management activities and within their scope of licensure directs the medical care of our members on behalf of our clients. This person works collaboratively with the Medical director team as well as the other medical management stakeholders such as provider relations, quality management, compliance, member services, benefits and claims management to ensure all client expectations and requirements are met.
Roles & Responsibilities
Accountable and reports into Director or Senior Director, Utilization Management
Supervise and manage a team of clinicians to meet the daily client performance requirements through regular performance feedback and coaching.
Implement initiatives and educational processes to achieve targeted utilization management results established by the client
Hire, onboard and direct client and market focused utilization management staff.
Monitor staffing ratios and identify the need for adjustments to ensure sufficient staffing is in place to meet growth or revised membership of the client.
Create workflows that provide for alignment and accountability with Evolent processes to effectively manage utilization management assignments by the provider network
Consistently monitor and review team performance to drive improvement of utilization management metrics over client baseline requirements.
Monitor, drive, and improve quality of daily utilization management workflows, managed directly or indirectly on behalf of the client, to improve efficiency for clinical team in completing reviews accurately and timely.
Manage the timeliness and accuracy of utilization management data and reporting to meet requirements of applicable regulatory agencies.
Implement and manage the utilization management work plan to meet monthly, quarterly and annual deliverables as per client contract, local, and federal regulatory requirements
Development and implementation of appropriate utilization management programs, policies, and process improvements.
Accountable for ensuring rigorous, consistent, and disciplined design and execution of integration of Utilization Management practices with the Evolent Health Quality Management program.
Using data analysis to identify and recommend opportunities for quality improvement.
Developing and adopting best practice methodologies and training programs for the clinical team to develop new skills when using utilization management tools and techniques.
Accountable for directing activities related to special projects for utilization management programs and use of project resources.
Ability to manage cases from UM queues as needed to meet TAT performance requirements (regulatory or client specific)
Qualifications
An active and unrestricted Nursing License in the Philippines and in the mainland US
At least 5 year experience in US healthcare with at least 2 years in a supervisory/managerial position
Minimum of two year experience of Utilization Management in a managed care setting
Strong clinical knowledge.
Strong written communication skills
Sophisticated knowledge of clinical operations in managed care, including quality management, outcomes, provider network, claims, financial management, care management policies, disease state and population management, members' rights and responsibilities, and ability to quickly assess client practices.
Reliable for driving and achieving a high standard of quality utilization management and results.
Working knowledge of clinical quality metrics such as HEDIS, NCQA and National Quality Forum metrics.
Strong oral written and interpersonal communication skills
Hours of Operations: US Business Hours
Compensation & Benefits
Earn over P100,000 monthly
HMO coverage includes you and a dependent.
Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.
Evolent Health intends to establish a great working environment in the Philippines and offers a competitive benefit package. Candidates offered a position must be able to successfully pass the background check. * Skills testing may be required. Employees will initially be hired by Genfinity with the expectation that they will be transferred to Evolent.
Genfinity

Makati City, Metro Manila
Permanent
Full-time