Manager Utilization Management

Job Summary

Effectively leads and motivates the Utilization Management team to ensure the goals and standards of the department are being met. This position is responsible for oversight and management of department functions including day-to-day management and training of staff, process improvement, letter review, updates, and compliance with regulations, system upgrades, provider appeals and auditing and overall outcomes of the department.

Essential Functions

• Provides operational management over the department including people, program administration and service delivery. Ensures integration of Health Management activities within and between teams as well as across the entire Medical Department and organization. Also responsible for departmental outcomes.
• In collaboration with other teams in Medical Operations, identifies, implements and monitors process improvement projects. Ensures applicable document workflows, policies and procedures are developed prior to implementation.
• Participates in the review, revision and approval of departmental policies and procedures; is accountable for compliance to policies and procedures pertaining to data entry and audit activities. Ensures applicable policies and procedures are implemented and adhered to.
• Reviews productivity measures and documentation to ensure compliance to processes and timelines. Performs (or oversees if delegated) quality review and audits of staff performance and regulatory standards.
• Delegates work to direct reports appropriately and effectively. Provides leadership, coaching and mentoring to direct reports. Effectively intercedes with other employees/department to resolve concerns related to staff or process. Plans and implements orientation and training of new-hire employees. Ensures staff is provided with adequate training and tools
• Serves on applicable internal committees and actively participate in Departmental, Corporate and Network activities as well as projects that improve the departments’ performance and outcomes.
• Develops and maintains expertise in all computer systems utilized by Health Management, co-ordinates testing of systems for the Medical Operations, communicates system problems and participates in all system up grades.
• Maintains expertise in administrative functions such as pended claims processes, OnBase workflow, Customer Service Inquiry work including report tracking/monitoring, letter development, revision and audit processes, oversees provider appeals, outlier reviews and denial management.

How Corewell Health cares for you

• Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
• On-demand pay program powered by Payactiv
• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
• Optional identity theft protection, home and auto insurance, pet insurance
• Traditional and Roth retirement options with service contribution and match savings

Qualifications

Required

• Bachelor's Degree in Nursing or related field (or equivalent education and experience)
• 3 years of relevant leadership
• 5 years of relevant clinical experience in acute care or office setting
• LIC - Registered Nurse (RN) from the State of Michigan upon hire

Preferred

• 5 years of relevant experience in managed care leadership
• Knowledgeable of compliance and regulations as it relates to medical operations

About Corewell Health

As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.

Primary Location

Department Name

Employment Type

Shift

Weekly Scheduled Hours

Hours of Work

Days Worked

Weekend Frequency

CURRENT COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.

Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.

You may request assistance in completing the application process by calling 616.486.7447.