Team Leader of Utilization Management

Location
Fargo, ND
Posted
Aug 09, 2017
Industry
General

Requisition Number 17-0494

Post Date 7/26/2017

Title Team Leader of Utilization Management

City Fargo

State ND

Description

JOB SUMMARY

The Team Leader of Utilization Management provides leadership and direction to the Utilization Management team, engaged in the review and resolution of provider requests for pre-service approval of significant medical care or pharmaceutical services as required by policy provisions. This position ensures department meets timeliness and quality standards related to Utilization Management, works with other areas in the company to maintain and improve pre-service review of services as well as special project implementation and monitors need and outcomes for process improvements related to function and goals of the company and the team.

ESSENTIAL FUNCTIONS

  • Selects, develops and manages a staff of nurses and technical personnel in the review, analysis, approval/rejection and resolution of provider requests for pre-service approval of medical care as required by policy provisions.
  • Establishes internal processes for the progressive review of pre-service requests, assuring that requests are processed and concluded in the most timely manner practical.
  • Establishes standards for review of pre-service requests and collaborates with staff nurse reviewers and other healthcare staff within the organization to assure that resources and decisions reflect current healthcare practices and company policy.
  • Supervises the maintenance and administration of multiple systems supporting the processing of pre-service requests and case management activities. Assures that systems are functioning correctly and that all staff are fully trained to utilize systems.
  • Reviews activity levels, response times, approval/rejection results, external feedback and other information to provide guidance in the management and improvement of the utilization review effort.
  • Oversees peer-to-peer training by staff for new staff members and for internal skills development.

Requirements

KNOWLEDGE, SKILLS AND ABILITIES

Staff Leadership: Basic

Attention to Detail and Accuracy: Intermediate

Nursing Expertise: Advanced

Problem Solving and Resolution: Advanced

Communication (Verbal/Written): Intermediate

Empowerment and Delegation: Intermediate

EDUCATION REQUIREMENTS

Required: Associate's

Preferred: Bachelor's

Field(s) of Study: Completion of RN program is required; BSN in Nursing is highly preferred.

EXPERIENCE REQUIREMENTS

Required: Minimum of 5 Years

Preferred: Minimum of 5 Years

Experience Details: Minimum of 5 years of clinical/patient care experience with at least 2 years in utilization review, pre-service review, case management or related is required; minimum of 1 year of supervisory/staff leadership experience is preferred.

CERTIFICATION, LICENSURES & REGISTRATION REQUIREMENTS

Title: North Dakota (ND) Registered Nurse (RN) License or RN License valid for work in ND

State or Agency: Board of Nursing

Equivalent combination of education, experience or training determined to be acceptable by Human Resources may be substituted, unless regulated by contract or program standards

PHYSICAL DEMANDS

Sitting: Frequent (60-90%)

Use of Computer: Frequent (60-90%)

Talking: Frequent (60-90%)

Telephones and Other Electronic Devices: Frequent (60-90%)

OTHER INFORMATION

Job Posting Policy 6.05

New employees with Blue Cross Blue Shield of North Dakota will be eligible to apply for positions within their assigned department after successfully completing a 90-day review. For positions outside your department, you must attain a minimum of six months of service before you can apply.

EQUAL OPPORTUNITY EMPLOYMENT

Equal Opportunity Employer of Minorities, Females, Protected Veterans and Individual with Disabilities, as well as Sexual Orientation or Gender Identity.

For questions, please email careers@bcbsnd.com

This job posting will be closed 08/14/2017 at 8:00AM CST. No further applications will be considered.

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