Under the supervision of the Director of Utilization Management, the Manager of Physical Health Utilization Management is responsible for developing and managing the physical health components of the Utilization Management Program for Colorado Access members with emphasis on high acuity levels of care and pharmacy benefit management. Responsibilities include supervising staff within the Utilization Management team, assessing, planning, implementing, monitoring and evaluating activities and services. The position will also be responsible for overseeing the implementation of specific projects and partnerships.
· Works closely with the Director of Utilization Management, the Manager of Behavioral Health Utilization Management, and Medical Directors to analyze physical health utilization and authorization trends (both inpatient and outpatient) for opportunities for cost savings, clinical interventions, or process improvements.
· Works closely with the Manager of Behavioral Health Utilization Management to initiate and coordinate efforts with EHR vendor to optimize functionality to meet the clinical needs of the department.
· Performs operational oversight of the Pharmacy Department, clinical pharmacists and the pharmacy benefit management vendor.
· Oversees tactical operations of the department, assuring compliance with all state, federal, and contractual obligations for physical health and pharmacy utilization review.
· Initiates and coordinates efforts with the Directors and Managers of Care Management, Contracting, and Business Intelligence for system/program development and improvement opportunities, which crosses populations and departmental functions.
· Performs oversight of employee productivity and performance, provides coaching and supervision to all direct reports. Engages in ongoing, real time, and comprehensive communications regarding current efforts, issues, progress, and barriers with other Managers and Directors, including the Director of Utilization Management as well as Directors and Managers of Care Management.
· Identifies issues, needs, and strategic proposals in the area of responsibility and pursues them actively and aggressively to completion.
· Assists the Directors and Managers of other departments in projects where the Manager’s knowledge, experience, and efforts can enhance the overall efforts of the company.
Education: Bachelor’s degree in Nursing or healthcare-related field.
Experience: Five years experience in a related field with two years supervisory experience required. Experience in a managed care setting and/or pediatrics preferred.
Knowledge, Skills, and Abilities: Strong working knowledge of pediatric treatment required, especially medical/surgical, NICU, rehabilitation, and pharmacy services. Knowledge of Medicaid/CHIP regulations, ICD/CPT/HCPC coding, care coordination/utilization management software, and provider contracting preferred. Position requires excellent written and verbal communication skills and the ability to establish good working relationships with supervisors and employees. Demonstrates support for the company’s mission, vision and values. Excellent time management skills with the ability to multi-task required. Must be able to prioritize work responsibilities and direct staff in a fashion that promotes team building and communication. May be required to manage multiple priorities and projects with tight deadlines. Must be proficient in Microsoft applications (Word, Access, Excel).
Licenses/Certifications: Active Colorado Nursing licensure is preferred. A valid driver's license and proof of current auto insurance will be required for any position requiring driving.
Additional Salary Information: Benefits: In addition to being part of a mission driven organization that serves our community, eligible Colorado Access employees receive a generous benefits package, including:
Medical, Dental, & Vision starting the 1st day of the month following start date.
Supplemental insurance such as critical illness and accidental injury.
Healthcare and Dependent care flexible spending account options.
Employer Paid Basic Life Insurance and AD&D (employee, spouse and dependent).
Short-term and Long-term Disability Coverage.
Voluntary Life Insurance (employee, spouse, dependent).
Paid Time Off
Tuition Reimbursement (based on eligibility).
Annual bonus program (based on eligibility, requirements and performance).
Internal Number: 154
About Colorado Access
We’re a locally based nonprofit health plan that’s been changing the health care landscape in Colorado for more than two decades. We are the only organization in Colorado caring for members across a continuum of health services, from Health First Colorado (Colorado’s Medicaid Program) physical and behavioral health to Child Health Plan Plus and long-term services and supports. Our broad view allows us to stay focused on our members’ unique needs while we create integrated systems to serve them better.