IPA Medical Manager - Shelby (190831-955)

Description

Primary Function:

Day to day supervision and operations of multiple IPA/PODs and staff who are responsible for the medical management processes, including but not limited to Utilization and Case Management.  Provide oversight and coordinate the utilization process to ensure adherence to Management Company Policies and Procedures.  Assist with development and revision of Policies and Procedures to ensure compliance with NCQA, CSMA, Health Plan Standards, state and federal regulations.  Assists the Director of Medical Management in the development, implementation and management of utilization management functions, including authorization processes, referral processes and retrospective reviews.  Serves as a management liaison with the local health plan and medical networks to ensure operational continuity.

 

Responsibilities:

·        Evaluates and ensures productivity and performance of all staff assigned to utilization review in the Medical Management Department.

·        Assists in the ongoing education and orientation of medical management personnel.

·        Supervises and participates in the medical management processes, including the coordination of case management and disease management opportunities for members.

·        Participates in the development of new programs/processes in Medical management and assists in the evaluation of the cost effectiveness of programs.

·        Assures the accuracy, completeness and timeliness of the approval and denial processes.

·        Works with other departments in a collaborative and goal directed manner to achieve department and company goals, (Claims, Provider Relations, Customer Service, and Administration).

·        Assists with the development, revision, and implementation of policies and procedures as necessary to comply with NCQA, TDI, CSMA, and Health Plan Standards.

·        Assists in the review of financial cost associated with referral trends and assists with the development and implementation of medical management action plans as appropriate.

·        Participates in corporate coding initiatives.

·        Assists in the TQM activities for medical management.

·        Provides input on system issues and enhancement.  Participates in the planning for future enhancements.

·        Participates and assists with processes for ongoing reporting of activities to the Director of Medical Management, GulfQuest Chief Medical Officer, IPA/POD Medical Directors, Senior Management, IPA/POD Administration and Health Plan Representatives as indicated.

·        Assists in developing process flows to assist staff in decision-making and problem resolution.

·        Assists in the orientation and communication with provider offices on medical management issues.

·        Supports and participates in the preparation of IPA/POD UM/QM/NAC and PCP meetings. Prepares packets, reports and maintains minutes for assigned IPA/POD.

·        Participates in strategic planning for assigned area of responsibility by assisting with establishing goals and objectives for assigned area of responsibility.

·        Participates in developing and trending quality monitors.  Tracks, trends and analyzes data as necessary.  Assists in developing and implementing corrective action plans based on findings accordingly.

·        Maintains confidentiality of all physicians, members and personnel issues. Actively establishes goals for personal and professional growth and development. Required Experience



·        A licensed practical nurse with leadership experience that is in pursuit of or has obtained a bachelor's degree in the business, health administration or nursing profession.

·        Current Nursing license in the State of Alabama.

·        Five years Clinical Experience

·        Three years experience in management care/IPA or related work in Health Services with an emphasis on process implementation, protocol development and administration.

·        Management Experience is preferred.