Manager of Clinical Services - Utilization Management

Amida Care, the largest Medicaid HIV Special Needs Plan in NY, delivers a uniquely effective care model that has become a true benchmark for innovation, engagement and member health outcomes. Our mission is to provide access to comprehensive care and coordinated services that facilitate positive health outcomes and general well-being for our members. This true integrative care model addresses psychosocial, housing, behavioral and medical services directly evolving around the needs of each member.

We are a community of individuals from diverse peoples who work together to actively foster a fair, equitable, inclusive environment where all employees receive an invitation to belong. Visit https://www.amidacareny.org for more information about the Amida Care culture.

We are actively seeking a highly motivated, innovative and experienced individual to join our team as the Manager of Clinical Services - Utilization Management. Compensation will be commensurate with experience.

Position Summary:

The position of Manager of Clinical Services - UM provides clinical oversight of Utilization Management (UM) activities and staff within the Health Services Department. Monitoring functions include the development of auditing programs/audit tools and regular auditing of UM processes and cases, including all documentation and correspondence in line with regulatory guidelines. The Manager would interact regularly with delegated UM vendors. This position will also review medical utilization management denials and appeals prior to final determination by the Medical Director.

Responsibilities:

• Provide regular oversight of Medical and Gender Affirming Services (GAS) UM processes ensuring all regulatory guidelines are followed.
• Track and process all medical/GAS UM appeals.
• Process all UM actions for Fair Hearing and External Appeals.
• Provide clinical review of Health Services complaints, working closely with the A&G department and the Manager of Clinical Services Operations.
• Develop and maintain comprehensive monitoring processes and tools related to authorizations, appeals, quality, case management, interrater reliability and data entry.
• Perform regular, proactive internal auditing to ensure that documentation, UM letters, controls and processes are appropriate and aligned with regulations and internal policies and procedures.
• Create monitoring reports, and follow up on findings and recommendations, i.e. length of stay reports.
• UM Point of contact for Medical Delegated vendor.
• Review all medical utilization management (UM) denials and appeals received from Medical UM vendor prior to final determination by the Medical Director.
• Review and process claims appeal as appropriate.
• Provide guidance, support and oversight into UM protocols, benefits and guidelines to the UM staff.
• Participate in the implementation and monitoring of corrective action plans from internal and external audits related to UM.
• Assist with report preparation for the Delegated Vendor Oversight and Quality Management Committees.
• Perform other duties as assigned.

Amida Care is Diversity, Equity and Inclusion employer committed to full inclusion and elimination of discrimination in all its forms. We strive to develop, promote and sustain a culture that values equity and leverages diversity and inclusiveness in all that we do.

EDUCATION REQUIRED

• Registered Nurse Bachelor's Degree.

EXPERIENCES AND/OR SKILLS REQUIRED

• Five (5) years' experience in a health plan offering Medicaid and/or Medicare Advantage plans.
• General knowledge of Medicaid Managed Care.
• Demonstrate intermediate PC skills using word, PowerPoint and Excel.
• Exhibit ability to work independently with attention to detail.
• Exhibit a strong commitment to objectivity.
• Exhibit a strong commitment to maintaining the integrity and effectiveness of the Health Services Department.
• Demonstrate interpersonal and verbal communication skills.
• Demonstrate ability to liaison with other departments.
• Demonstrate ability to research facts regarding compliance issues and incidents.
• Demonstrate understanding and sensitivity to multi-cultural values, beliefs, and attitudes of both internal and external contacts.
• Demonstrate appropriate behaviors in accordance with the organization's vision, mission, and values.