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Nurse Manager for Healthcare Programs and Utilization Management

Department: Healthcare Management
Reports To: Director of Healthcare Programs

Position Overview:

In conjunction with the Director of Healthcare Programs and the Chief Medical Officer (CMO), the Nurse Manager for Healthcare Programs and Utilization Management position includes, but is not limited to, managing, reviewing and tracking of member assessments for homecare services, management of the utilization and case management programs for PHP Medicaid products and participation in other healthcare programs such as telemedicine and proactive and preventive care services at the discretion of the Director.

Duties and Responsibilities:

  • In conjunction with the Director of Healthcare Programs and the Chief Medical Officer (CMO), the Nurse Manager for Healthcare Programs and Utilization Management position includes, but is not limited to, managing, reviewing and tracking of member assessments for homecare services, management of the utilization and case management programs for PHP Medicaid products and participation in other healthcare programs such as telemedicine and proactive and preventive care services at the discretion of the Director.

Qualifications:

  • Licensed RN in state of New York; BSN preferred.
  • Experience in managed care utilization review (5 years minimum); full working knowledge of Medicare and Medicaid systems. Experience in the UAS process and the use of tasking tools (5 years minimum).
  • Management experience regarding utilization management programs, both Medicaid and Medicare including the appeals process; Management experience with regard to the use of assessment processes, tasking tools with regard to Medicaid including the appeal process.
  • Prior experience in working to support a special needs population preferred.
  • Experience working collaboratively with various departments in fast-paced environment; Experience in utilizing decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.

Requirements of All Positions:

  • All employees shall meet PHP’s Compliance and Privacy Regulations, and attend at a minimum of one (1) hour of Compliance and Privacy educational training annually;
  • All employees shall master PHP’s Model of Care and complete all training requirements within the first thirty (30) days of employment and annually thereafter, or as required by state and federal regulations;
  • All employees are required to maintain confidentiality, protect privacy, comply with Protected Health Information regulations, and report violations;
  • Perform functions as they relate to “Improving Health Care Quality” as defined in the National Association of Insurance Commissioners Supplemental Health Care Exhibit that:
    1. Improve health outcomes;
    2. Prevent hospital readmission;
    3. Improve patient safety and reduce medical errors, and
    4. Provide wellness and health promotion activities.

Physical Demands and Work Environment:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or fingers, handle or feel utilize objects, tools or controls. The employee is occasionally required to stand; walk; sit; reach with hands and arms; climb or balance; and stoop, kneel, crouch or crawl.

The employee must occasionally lift and/or move up to 25 pounds, and infrequently up to 50 pounds. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision, and the ability to adjust focus. The noise level in the work environment is usually moderate.

Equal Opportunity Employer

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