Exl Service

  • Supervisor, Utilization Management (Medical)

    Job Location US-FL-Tampa
    ID
    2018-6267
    Group
    Operations Management
    Type
    Regular Full-Time
  • Overview

    Why join EXL?
    At EXL, were more than just an analytics, operations management, and technology Company. We focus not only on our outstanding Team Members, but on our growing industry as well.
    Headquartered in NYC, EXL has more than 27,000 professionals situated in locations throughout the United States, Europe, Asia, Latin America, and South Africa.

    Our EXL Team Members receive the benefit of:
    Valuable Compensation Package:
    • Competitive Wages
    • Work-Related Expense Reimbursement
    • Annual Discretionary Bonuses
    • Team Member Referral Bonuses
    Comprehensive Health & Welfare Benefits:
    • Group Medical, Dental and Vision Benefits
    • Flexible Spending Accounts and Health Savings Accounts
    • Generous Paid Time Off, Sick Days and Holiday Pay
    • Group Life Insurance, LTD and 401k Retirement
    Inviting Culture & Team-Oriented Philosophy:
    • Exciting Work Environment
    • Casual Dress Code
    • Monthly Team and Company Events
    • Team Member Appreciation Awards
    • Remote, Home-Based Opportunities
    • Opportunities for Upward Mobility

     

     

    The Utilization Management Supervisor completes, monitors and directs UM Program activities including prospective concurrent, retrospective review and outcomes analysis.

    Responsibilities

    • Facilitates and ensures that day to day UM activities result in effective and appropriate use of healthcare services by:
        o Conducting and coordinating medical necessity reviews: including prior authorization and retrospective requests
        o Reviewing and triaging hospital notifications: including concurrent review and discharge planning
        o Serving as a liaison and resource to internal and external customers
        o Assisting in the evaluation and implementation of improved work flows

        o Identifying high risk and high cost patients with complex medical or psychosocial needs for referral to case management


    • Serves as resource to UM staff for requests that are complex or require extensive research.
    • Assists and supports all related processes including development of policies and procedures as requested.
    • Reviews hospital notifications and conducts concurrent reviews for length of stay, medical appropriateness and assessment of discharge planning needs.
    • Consults with licensed physicians and/or Medical Directors as needed to make medical necessity determinations and develop medical policies.
    • Identifies high risk and high cost patients for referral to case management.
    • Coordinates with case managers and provides support as needed.
    • Serves as a liaison to customer service representatives and referral staff to answer medical management questions which require a medical background or knowledge of medical management procedures.
    • Assists with pre-existing condition (PEC) determinations by providing medical reviews as determined appropriate by the Medical Director.
    • Maintains appropriate documentation of all activities. Enters authorization for plan-approved services into the claims payment system to insure proper payment of claims.
    • Reviews cases using MCG criteria, CMS criteria or other clinical criteria designated by EXL
    • Completes authorizations or denials within required turn-around timeframes.
    • Provides clarification and feedback as needed on coverage determinations.
    • Participates in the development, measurement and monitoring of utilization reports.
    • Assumes leadership role for regulatory audits as needed for NCQA, URAC, CMS and other regulatory bodies.
    • Responsible for hiring and disciplinary actions for those supervised.
    • Responsible for performance plans, annual evaluations and other supervisory HR paperwork and processes.
    • Responsible for accuracy of all associated desk procedures and policies.
    • Responsible for auditing staff to meet work expectations and department goals.
    • Responsible for coaching and counseling staff as needed.
    • Other duties as assigned.

    Qualifications

    • Able to work well with others in a collaborative and respectful manner.
    • Able to multi-task, deal with complexity on a frequent basis.
    • Performs all functions of the job accurately and in a timely manner.
    • Able to work under pressure and time constraints.
    • Able to arrive for work on time and maintain a good attendance record.
    • Ability to maintain a professional demeanor and confidentiality

     

    Education:

    Required: Current, unrestricted RN licensure
    Preferred: Bachelor of Science in Nursing

     

    Work Experience Requirements:

    Experience working in a managed care or payer environment preferred.
    Experience with medical claim review, and /or case management preferred.
    Experience with Utilization Management required
    Experience with Medicare/Medicaid population required.
    Two or more years supervisory experience preferred, including lead positions.
    Two or more years clinical nursing experience preferred.

     

     

    EEO Statement

    EEO/Minorities/Females/Vets/Disabilities

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