✨ About The Role
- Supervise the day-to-day operations of medical management, utilization, and case management functions
- Oversee changes to medical service functions and performance in relation to company mission, philosophy, objectives, and policies
- Ensure compliance with established onsite and concurrent review, case management, referral, pre-authorization policies, procedures, and processes
- Coordinate Medical Services functions and responsibilities with other operating departments of the Plan and Corporate
- Participate in NCQA accreditation of the Plan and case review with Medical Directors
âš¡ Requirements
- Experienced nursing professional with a state registered nursing license and advanced degree preferred
- Skilled in quality improvement, case/utilization management in a healthcare environment, preferably managed care
- Previous experience leading in a functional area or managing cross functional teams on large scale projects
- Strong analytical skills with the ability to conduct statistical analysis of utilization data
- Ability to balance current and future needs effectively and assist in strategic planning and key initiatives