Utilization Management Supervisor

This position is responsible for assuring that all clients’ patients and providers’ needs are met by receiving phone calls from both members and phone calls and faxed referrals from providers. Activities implemented are to facilitate the authorization and coordination of referrals utilizing pre-approved screening criteria in compliance with contracted Client's requirements. UM Supervisor has to be a competent, knowledgeable resource for information. Under the direction of the Utilization Management Director, supervises the Coordinators and provides them with leadership to ensure high quality results.

  • Assures that UM authorization coordinators are available to receive phone calls and faxed referral requests from providers. Assists UM authorization coordinators with phone calls and referral requests as necessary. Is resource person for all coordinators for all clients’ utilization management activities.
  • Monitors incoming faxes and distributes work among the authorization coordinators.
  • Is liaison between providers and UM authorization department, trouble shoots any problems arising in UM Authorization process and reports to supervisor as well as to appropriate departments.
  • Assists with compiling monthly utilization management statistics.
  • Reviews monthly phone statistics and phone criteria with Director of Utilization and comes up with corrective action plan as necessary.
  • Assists with quarterly inter-rater reliability reports of non-clinical UM staff.
  • Assures that authorization coordinators are in-serviced on all various clients’ products.
  • Ensures that departmental and organization goals are met.
  • Ensures that Coordinator meet productivity requirements.
  • Identify and facilitates training needs on Coordinators.
  • Ensures that all requests are timely processed.
  • Ensures that Coordinators maintain a professional and productive behavior.
  • Ensures that daily reports are timely monitored.
  • Makes sure all authorization coordinators are instructed and well versed in the following duties:
    • Verification of member eligibility and benefits for client plans.
    • Inputs all referral requests including ICD-9 and CPT codes into system accurately for electronically generated authorization tracking.
    • Provides referral authorization to external providers per UM Departmental Policy and Procedures and specific contracted Client's process.
    • Requests submission of appropriate medical records according to established criteria for requested service(s).
    • Issues authorization within appropriate timeframe for routine, urgent and emergent requests.
    • Appropriately forwards all referral requests to the next level of review.
    • Coordinates approved outpatient surgical procedures in specialist's office and/or outpatient surgical facilities with health plan's authorization department when applicable.
    • Coordinates approved services with Home Health Providers, Plan discharge Planners and Plan Members as delegated or required by Plan
    • Is resource person for PCP to refer to network specialist(s).
    • Distributes correspondence and other information to the appropriate parties or departments.
    • Maintains appropriate logs, records, and reports as established by Utilization Department.
    • Documents and communicates areas of concern to supervisor.
    • Identifies providers who are problematic with plan requirements.
    • Adheres to company HIPAA policies and procedures.
    • Ensures integrity of data entry is accurate
  • Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
  • Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
  • Ability to come to work and work the regular schedule and shift for the position.
  • Compliance with all personnel policies and procedures.
  • Perform additional duties and related essential duties as assigned.

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Supervisory Responsibilities

This job has supervisory responsibilities as well as teaching responsibilities to assure quality performance of UM authorization staff.

Required Education and Experience

High school diploma or general education degree (GED); Supervisory and Utilization Management experience, preferably in a managed care setting, for at least a year, solid knowledge of medical terminology, CPT & ICD-10 Coding, Medicare and Medicaid requirements.

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