Registered Nurse RN Supervisor Prior Authorization/UM Healthcare WellMed Texas

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The Supervisor of Prior Authorization/Utilization Management Services is responsible for the supervision, evaluation and direction of the Utilization Compliance and Quality Management process. The position will ensure compliance with the utilization management program for all pre service requests and empowers team members through active problem solving and resource direction. The position is a resource for difficult or complex and/or exceptional preauthorization requests. The supervisor successfully impacts assigned team and organization by mentoring those who wish advancement and engages in departmental process improvement teams and activities. In addition, the Utilization Management Supervisor is responsible for timely completion of documentation audits and reviewing and mentoring team members to meet and exceed all documentation compliance standards. This position mentors and trains staff in the completion of timely, accurate um determinations and functions as an advisor to Physicians and lower level utilization management staff.

If you are located in a Wellmed Location, you will have flexibility to telecommute* as you take on some tough challenges

Primary Responsibilities:

• Assist in development of training materials; acts as Subject Matter Expert
• Fields questions and serves as a resource for Clinicians and non-clinicians Assists with reviews and updates job aids to maximize quality and productivity
• Trend, analyze and improve processes and suggests improvements
• Supports utilization management operations across the continuum of care (assessing, planning, implementing, coordinating, monitoring, and evaluating)
• Oversees utilization management functions and ensure compliance with application of criteria from approved standardized guidelines, government mandated regulations and contractual agreements
• Plans, organizes and oversees staff to ensure timely completion of um determinations
• Ensures team meets established performance metrics and medical cost reduction goals. Includes timely reporting of monthly metric reports
• Adapts and collaborates with management on departmental plans and priorities to address business and operational challenges
• Oversees the team's daily staffing requirements to meet program standards
• Implements and interprets organizational policies and procedures, reviews work of staff to ensure that policies and guidelines are appropriately applied
• Analyze, communicate results/trends, and collaborate with leaders to develop action plans for key reports: TAT Report, Quality audits and any other additional team specific reports
• Tracks and trends outcomes for potential improvements in the utilization management process
• Interviews, hires, and retains staff in collaboration with management to meet the needs of the department
• Evaluates staff performance and conducts merit increases, and disciplinary actions on staff as needed
• Conducts annual evaluations of team members in a timely basis; provides feedback in a constructive manner and respects the confidentiality of personnel issues
• Monitors and oversees the reporting of all quality issues to medical management leadership for referral and reporting to health plans as appropriate
• Monitors appropriate utilization of resources, overtime, and supplies
• Reviews difficult and/or exceptional preauthorization requests while assisting with any escalated issues from providers
• Performs all other related duties as assigned
• The position requires rotating Saturday shift / Additional Saturday shifts will be required as determined by the business

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Current unrestricted Texas RN license or compact license
• 5+ years of healthcare experience to include experience in a managed care setting, hospital setting and/or physician practice setting, or similar experience
• 1+ years of demonstrated supervisory or management experience with responsibility for team performance management
• Solid experience with MS office including Word, Excel and Outlook with proficient ability to navigate in a Windows environment
• Ability to establish and maintain effective working relationships with employees, managers, healthcare professionals, physicians and other members of senior administration and the general public

Preferred Qualifications:

• Bachelor of Science in Nursing (BSN) or (Four additional years of experience beyond the required years of experience may be substituted in lieu of a bachelor's degree)
• Data mining, analytical and reporting skills with the ability to review and interpret data to make recommendations to leadership
• In and /or out-of-town travel as deemed necessary by business need
• Solid organizational skills and multitasking abilities

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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