Registered Nurse (RN) Utilization Management (UM) Manager - KS MCD - 51680BR


Overland Park, KS
United States

Job Description
Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of Kansas is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of KanCare members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of Kansas, and we will support you all the way.

POSITION SUMMARY
This position is responsible for Utilization Management (UM) activities, including but not limited to overseeing concurrent review and prior authorizations. This position develops, implements, supports, and promotes Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Aetna. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies. The UM Manager oversees and manages UM and Prior Authorization clinical team processes including the organization and development of high performing teams.

This position has the potential to require up to 25% in-state travel.

Fundamental Components:
- Ensures all UM staff have appropriate clinical licensure and experience in order to make UM decisions.
- Responsible for coordinating with the Behavioral Health and LTSS Medical Officers, Pharmacy Director and Behavioral Health Supports Director and other network staff to ensure delivery of holistic, integrated and person-centered care.
- Reinforces clinical philosophy, programs, policies and procedures.
- Communicates strategic plan and specific tactics to meet plan.
- Ensures implementation of tactics to meet strategic direction for cost and quality outcomes.
- Creates direction and communicates a business case for change by focusing on and addressing key priorities to achieve business results.
- Identifies opportunities to implement best practice approaches and introduce innovations to better improve outcomes.
- Accountable for meeting the financial, operational and quality objectives of the unit.
- May be accountable for the day-to-day management of teams for appropriate implementation and adherence with established practices, policies and procedures if there is not supervisor position
- Works closely with functional area managers to ensure consistency in clinical interventions supporting our plan sponsors.
- Develop, initiate, monitor and communicate performance expectations.
- May act as a single point of contact for the customer and the Account Team which includes participation in customer meetings, implementation and oversight of customer cultural requirements, and support implementation of new customers.
- Participate in the recruitment and hiring process for staff using clearly defined requirements in terms of education, experience, technical and performance skills.
- Assesses developmental needs and collaborates with others to identify and implement action plans that support the development of high performing teams.
- Consistently demonstrates the ability to serve as a model change agent and lead change efforts.
- Accountable for maintaining compliance with policies and procedures and implements them at the employee level.
- Evaluate and interpret data, identify areas of improvement, and focuses on interventions to improve outcomes.
- Dedicated advocate for plan and members.

Qualification Requirements:
- 7+ years experience in clinical area of expertise required.
- Managed Care Organization (MCO) experience is required (minimum of 3-5 years in a MCO setting strongly preferred).
- Minimum of 1-3 years supervisory or management experience required.
- Active unrestricted Kansas State Registered Nurse (RN) Licensure required (BSN preferred).
- Computer literacy and advanced proficiency with Microsoft Excel, Word, and web-based applications and Access databases is required.
- Reporting: ability to understand and create reports with productivity and service metrics; identify gaps; ability to evaluate and interpret data, to identify areas of improvement, and focus on interventions to improve outcomes required.
- Demonstrated ability to deliver presentations to both internal and external customers required.
- Knowledge of community resources and provider networks required; familiarity with local health care delivery systems.
- Experience working with diverse teams and populations required.
- Strong communication and organizational skills with an attention to detail required.
- Policy and procedure experience with a demonstrated ability to operationalize policies to desktops required.
- Ability to work with people in such a manner as to build high morale and group commitment to goals and objectives required.
- Behavioral Health experience is strongly preferred.
- IDD (Intellectual or Developmental Disability) experience is strongly preferred.

Education:
The minimum level of education required for candidates in this position is an Associate's degree or equivalent experience.

Licenses:
Active unrestricted Registered Nurse (RN) License for State of KS is required.

FUNCTIONAL EXPERIENCES
Functional - Clinical / Medical/Direct patient care (hospital, private practice)/7-10 Years
Functional - Medical Management/Medical Management - Concurrent Review/7-10 Years
Functional - Medical Management/Medical Management - Discharge planning/7-10 Years
Functional - Medical Management/Medical Management - Precertification/7-10 Years
Functional - Medical Management/Medical Management - Managed Care/Insurance Clinical Staff/4-6 Years

TECHNOLOGY EXPERIENCES
Technical - Desktop Tools/Microsoft Word/7-10 Years/End User
Technical - Desktop Tools/Microsoft Outlook/7-10 Years/End User
Technical - Desktop Tools/TE Microsoft Excel/7-10 Years/End User
Technical - Desktop Tools/Microsoft SharePoint/4-6 Years/End User

ADDITIONAL JOB INFORMATION
Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit eligibility may vary by position.

Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

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