Work with Director of QM to oversee Quality Improvement and assimilate results of Quarterly/Annual Reports, implementing changes if needed.
Assists in preparing annual client reports.
Acts as a liaison with MIS, Claims and all other departments at Alico on Managed Care Software issues.
Is available to provide training as needed to Alico Staff - some travel required.
Acts as primary contact at AMM for Managed Care Software issues - working with Managed Care Software Vendor in resolving Managed Care Software problems that cannot be resolved at AMM or with
the assistance of MIS/Alico.
Coordinates training of new Utilization Management and Case Management staff at AMM.
Acts as a liaison with staff at Alico regarding medical necessity issues.
Works with the management team to identify goals and objectives for AMM.
Prepares ISR’s to send to MIS/Alico when changes are requested or needed.
Monitors RN license renewals.
Oversees and assures timeliness of monthly billing done by Case Management department.
Oversees daily and weekly productivity of Utilization Review and Case Management teams working to implement changes where needed.
Assists in monitoring of State licensing.
In conjunction with Management team oversees office committees.
Assists in completion of RFP’s.
Works with Medical Director in maintaining and developing clinical criteria in Managed Care Software.
Oversees and directs the efficiency of the workflow for Utilization Review and Case Management Departments.
Serves as a resource to team members in resolving clinical and/or policy questions.
Communicates with team members the department’s objectives, standards, and expectations. Develops objectives and standards in conjunction with management.
Researches and resolves customer service problems regarding specific cases and/or policies. Communicates problems and resolution to management, other departments and callers.
Interview, hire, train, and develop assigned employees, and evaluate team member’s performance. Provide feedback whenever needed to employees and management.
Reports to management the individual performance of departments as it relates to service, clinical knowledge, case review, and productivity. Completes and/or delegates as appropriate,
written performance evaluation of team members.
Develop and implement the clinical and operational policies and procedures. Review and update periodically.
Promotes a positive and cooperative working relationship among Management and other departments.
Oversees staffing needs of the departments and coordinates time off requests to ensure adequate staffing levels for the Departments.
Identify potential risk management issues with timely F/U.
Fiscal responsibility/accountability as outlined in Budgetary Process.
Key contact for clients during implementation and upon completion of implementation of new Utilization Review clients.
