Utilization Management Director jobs in Winston Salem, NC

• 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

Primary Purpose of Position: The primary purpose of this position is to supervise the IDD team which evaluates medical necessity, appropriateness and efficiency of the services requested for authorization against established criteria adopted by Partners Behavioral Healthcare Management.

Role and Responsibilities:

• To ensure IDD Utilization Management Reviewers respond to IDD requests for authorization from IDD Care
• Managers and Providers with appropriate authorization decisions that are guided by Clinical Policy.
• To ensure services are based on individual need and standardized procedures.
• To supervise the review and authorization of initial Plans of Care (POC), Continuing Need Review (CNR) and any revisions to the annual plan within expected turn-around –time.
• Consulting with Care Managers/Providers/enrollees regarding authorization requests.
• Monitor work flow and volume of work
• Supervision of IDD Utilization Management Reviewers.
• Provide training for IDD Utilization Management staff
• Work with IDD Care Managers and Provider Network staff to provide Technical Assistance to providers
• Participate in various departmental committees as assigned by the UM Director
• Participate in Mediations and other Appeal Proceedings as a representative of the MCO
• All other duties as assigned

Knowledge, Skills and Abilities:

• Extensive knowledge IDD diagnoses, treatment interventions and evidence-based practices for this disability and co-occurring behavioral and medical disorders
• Knowledge of 1915(b)(C) waiver, Supports Intensity Scale, Clinical Policy and clinical guidelines as they relate to authorization of services
• Awareness of cultural diversity as it applies to the treatment needs of major ethnic/racial groups served by the organization
• Exceptional interpersonal and communication skills
• Excellent computer skills including proficiency in Microsoft Office products (such as Word, Excel, Outlook, and PowerPoint)
• Problem solving, negotiation, arbitration, and conflict resolution skills
• Detail-oriented, able to organize multiple tasks and priorities and to effectively manage projects from start to finish
• Ability to make prompt independent decisions based upon relevant facts, to establish rapport and maintain effective working relationships

Education/Experience Required: A Degree in a Human Services field with clinical licensure and at least three (3) years of experience in I/DD services or a Registered Nurse with three (3) years of experience in I/DD services, including three (3) years Administrative Supervisory experience.

Education/Experience Preferred: A Master’s Degree in a Human Services field with clinical licensure and at least three (3) years of experience in I/DD services or a Registered Nurse with three (3) years of experience in I/DD. Previous experience in Utilization Management.

Licensure/Certification Requirements: Current unrestricted license with the appropriate professional board of licensure in the state of North Carolina. Licensed to practice as a Registered Nurse in North Carolina by the N. C. Board of Nursing or Independent License in NC as a LCSW, LPC, LPA, LMFT. An Associate license does not meet the requirements. An employee may be dual licensed with one of the specialties listed here can also be licensed as an LCAS. NC DMA contract requirements does not allow for an LCAS to be a standalone license for working in UM.

Employee is responsible for complying with respective licensure board’s continuing education/training requirements to maintain an active license.