I/DD Utilization Management Reviewer Lead, QP (Remote-NC)

Competitive Compensation & Benefits Package!  

Position eligible for – 

• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs
• Public Service Loan Forgiveness Qualifying Employer

See attachment for additional details. 

Office Location:  Flexible for any of our office locations: Remote Option

Projected Hiring Range:  Depending on Experience

Closing Date:  Open Until Filled

Primary Purpose of Position:  

This position is responsible for supporting operations of the IDD section of the UM department and acts as a liaison between UM Reviewers and Peer Reviewers; Support and technical assistance is provided to UM Reviewers, Supervisor, Manager, and Director as well as other Partners departments and external providers in relation to utilization management.

Role and Responsibilities:

• Acts as liaison between UM Reviewer and Peer Reviewers. 
• Tracks Peer Reviews for turnaround time and quality assurance.
• Summarizes monthly Peer Review data and provide analysis of UM Decisions
• Assists with developing and presenting UM specific trainings both internally and externally
• Provides technical assistance to Providers and Internal Staff regarding system concerns
• Completes productivity data (TAT and Volume) for the I/DD UM team 
• Completes QA Data/Reporting for the I/DD Utilization Management Review Team.
• Identifies systemic issues with Providers' submission of SARs 
• Prepare and analyze Enhanced Rates reporting and Innovations Residential/Supervised Living (Burns data).
• Prepares and analyzes Innovations Budget Variance Data 
• Processes authorization requests for all levels of care to support fellow UM Reviewers as requested by UM leadership during periods of high volume and to ensure coverage
• Completes internal audits and identifies areas of needed training within the IDD UM Team
• Additional duties and projects as directed by UM leadership in coordination with Chief Medical Officer.
• Maintain NC-SNAP data and all data entry for State NC-SNAP reporting. 
• Represent Partners UM on statewide Alpha Users call.
• Provide support for some supervisor activities as needed for back-up. (Daily SAR reports, assignments, cases over 14 days.
• Requests to move from Standard Plan to Medicaid Direct – process and manage spreadsheet.  Complete troubleshooting as needed.  
• Provide staff training and development for on boarding new staff and seasoned staff.  
• Provide quality assurance for manual letters and letter statements.  
• Report issues to the Supervisor, Manager, and Director that require that level of attention.
• Other duties as needed to support the Supervisor, Manager, and Director.

Knowledge, Skills and Abilities:

• The Team Lead is a versatile position that requires flexibility, initiative, leadership skills, organization, and the ability to multi-task.
• Comprehensive knowledge of I/DD as well as mental illness and other diagnostic categories.
• Knowledge of the assessment and treatment of developmental disabilities, with or without co-occurring mental illness, is a necessity. Additionally, the incumbent should be able to learn and understand legal, waiver and program practices/requirements and apply this knowledge in problem-solving and responding to questions/inquiries.
• Knowledge of the 1915 (b) (c) waiver.
• Knowledge of psychiatric medications and side effects.
• Knowledge of evidence-based practices.
• Knowledge of appropriate treatments for major diagnostic categories.
• Exceptional interpersonal skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts and established processes.
• Problem solving, negotiation and conflict resolution skills are essential to balance the needs of both internal and external customers.
• Awareness of cultural diversity.
• Excellent computer skills including proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.).
• Ability to make prompt decisions based on relevant facts.
• Detail oriented, able to independently organize multiple tasks and priorities, and to effectively manage an assigned caseload under pressure of deadlines.

Education and Experience Required:  A Bachelor’s Degree in a Human Services field and two (2) years of post-degree IDD experience or Bachelor’s Degree and four (4) years post-degree IDD experience.

Licensure/Certification Requirements:  N/A