Skip to main content

This job has expired

Quality & Utilization Management Specialist

Employer
PrimeWest Health
Location
Alexandria, Minnesota (US)
Salary
Salary DOE

View more

Job Details

This position is responsible for providing assistance and support to the Utilization Management Manager, the Director of Quality & Utilization Management, and the Utilization Management (UM) team. This position will develop a deep understanding of all PrimeWest Health’s regulatory and business needs and will conduct business in an efficient manner.

 

  • Reporting Accountability
  • This position is responsible for meeting the following regulatory, contractual, or other requirements on behalf of PrimeWest Health:

     

    1. Comply with Centers for Medicare & Medicaid Services (CMS) and Minnesota Department of Human Services (DHS) contracts
    2. Ensure compliance with all regulatory and contractual requirements related to the Quality & Utilization Management department
  • Maintain knowledge of National Committee for Quality Assurance (NCQA) standards
  •  

     

    Role and Key Responsibilities
    Assist the Utilization Management Manager, the Director of Quality & Utilization Management, and PrimeWest Health staff in the following as needed:
    1. Report and Application Submission
    2. Submit departmental regulatory reports to DHS via the Minnesota Information Transfer System (MN-ITS)
    3. Assist the Director of Quality & Utilization Management with personnel and budgeting
    4. Coordinate JIRAs for applicable requests
    5. Coordinate CE Direct questions, run reports, and maintain user profiles
  • Support Functions
  • Triage phone calls related to UM
  • Assist with monthly UM denial, termination, and reduction (DTR) of services audit
  • Assist UM team with printing and mailing UM-related materials and documentation from CareConnect (CCNT) and verify protected health information (PHI) prior to mailing
  • Assist with miscellaneous UM-related projects and initiatives including those related to NCQA standards
  • Assist in the timely processing of Service Authorization requests sent via electronic fax including retrieving web portal notifications, receiving/retrieving electronic documents and faxes from M-Files, and attaching documents to member files in CCNT
  • Assist with data entry into CCNT. This includes starting events for requests received by phone, fax, or mail and assigning the event to the appropriate UM care coordinator and completing approvals for inpatient admissions, targeted case management, and other UM certification requests.
  • Assist with quality improvement activities and/or auditing processes related to areas of concern
  • Assist with any internal collaborative efforts relating to request about informational notices from the Provider Network Administration and Membership & Program Development departments
  • Assist with any internal collaborative efforts relating to Quality/Complaints, Appeals, or Grievances notifications with the Quality/Complaints, Appeals, and Grievance staff
  • 3.   Other

     

  • Create, update, and post all Quality & Utilization Management workflows to Confluence
  • Maintain and create annual performance reviews for all Quality & Utilization Management staff and update job descriptions
  • Assist department with NCQA accreditation, Model of Care (MOC), CMS audit, and request for proposal (RFP) processes
  • Maintain the Quality & Utilization Management page on Confluence
  • General PrimeWest Health Responsibilities
    1. Abide by the PrimeWest Health Code of Conduct
    2. Comply with all PrimeWest Health policies and procedures
    3. Comply with the Health Insurance Portability and Accountability Act (HIPAA) and all other privacy laws
    4. Be familiar with building safety procedures and alert maintenance if something requires attention
    5. Keep public areas of the department and office neat and clean
    6. Conduct other responsibilities and activities as needed and assigned
    Professional Competencies – NA  

     

    Educational Requirements and Required Qualifications
    1. At minimum, an associate degree in business management administration
    2. Demonstrated knowledge of, and proficiency in, Word, Excel, and Outlook required. Experience with data entry and taking meeting minute taking is a plus.
    3. Flexibility and ability to handle multiple tasks. Demonstrated organizational skills and attention to detail. Ability to work effectively with a variety of people both within and outside of the organization. Good verbal and written communication skills.
    4. Ability to sit at a desk or computer station most of the time. Ability to occasionally lift and/or carry such articles as file folders and small boxes up to 30 pounds.
    Appropriate Licensure and Certification Requirements – N/A Collaborative Efforts with Other Departments
    1. Administrative Services
    2. Business IT Research & Development
    3. Care Management
    4. Compliance
    5. Communications
    6. Information Systems & Technology
    7. Membership & Program Development
    8. Provider Network Administration
    Supervision – N/A

    This position description is not to be construed as an exhaustive statement of essential functions or responsibilities.

    Location: Alexandria, Minnesota

    PrimeWest Health will accept resumes for this position through August 3, 2018. No phone inquiries please.

    Employment to begin approximately August 13, 2018.

    Qualified candidates should submit their resume and cover letter to:

    Monica Simmer, Utilization Management Manager

     

    3905 Dakota St

     

    Alexandria, MN 56308

     

     

     

    or

     

     

     

    monica.simmer@primewest.org

     

    Please include “Quality & Utilization Management Specialist” in the subject line.

Company

Located in Alexandria, MN, we are a partnership of greater Minnesota counties that have joined together to find innovative solutions to meet the health care needs of our communities.

We’re glad you’re thinking about a career at PrimeWest Health. We pride ourselves on being a customer-centered health plan committed to excellence, innovation, and, above all, providing the best possible services and programs for our health plan members. And all this starts with our most valued and important resource—our employees.

PrimeWest Health is always looking for ways to improve our organization through hiring, developing, and retaining motivated employees to maintain that professional yet personal touch that connects us with our customers and to one another—and that separates us from other health plans. This means that a career with PrimeWest Health offers more than just a paycheck. (But yes, we do also provide paychecks.)

Company info
Website
Location
Alexandria
Minnesota
56308
United States

Get job alerts

Create a job alert and receive personalized job recommendations straight to your inbox.

Create alert