Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. 

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

The Manager, is responsible for clinical and operational oversight and management of the team who supports the Utilization Management (UM) department through oversight and auditing activities, among others. This responsibility includes ensuring that documentation and operations align with UM department policies and procedures to maintain a compliant, efficient, and cost-effective UM Program that prioritizes the customer experience and quality of patient care. --This position is also responsible for the routine management, oversight, and auditing of Capital’s delegated UM vendors and ensuring that their activities align with the contract, service level agreements, and all regulatory and accreditation requirements. --Support for other UM department activities, including internal and external audit and accreditation activities, CMS reporting requirements, Inter-Rater Reliability Assessments, and Mental Health Parity and Addictions Equity Act (MPHAEA) UM activities, are additional responsibilities of this position.

• Provides clinical oversight and management of UM audit activities.
• Leads and coordinates UM audit activities.
• Audits UM activities to ensure compliance with established timeframes and standards of performance in accordance with the National Committee for Quality Assurance (NCQA), the Department of Health (DOH), Centers for Medicare and Medicaid Services (CMS), and other state and federal regulatory requirements.
• Prepares and presents audit findings to UM leadership, corporate and Medicare compliance and/or the Quality and Accreditation team as appropriate.
• Ensures sample size and frequency of audits is appropriate for the population.
• Follows through on audit findings and any remediation plan(s) to completion with the applicable business area.
• Uses data to monitor trends and recommend process improvement activities.
• Ensures that documentation and operations align with UM department policies and procedures to maintain a compliant, efficient, and cost-effective UM Program.
• Coordinates and supports delegated UM vendor management and oversight activities.
• Ensures delegated UM vendor activities align with the contract, service level agreements, and all regulatory and accreditation requirements.
• Leads and coordinates delegated UM vendor audit activities.
• Prepares and presents audit findings to UM leadership, corporate and Medicare compliance and/or the Quality and Accreditation team as appropriate.
• Follows through on audit findings and any remediation plan(s) to completion with the applicable vendor.
• Monitors vendor compliance activities.
• Facilitates delegated UM vendor meetings; tracks outstanding deliverables.
• Responsible for review and interpretation of delegated UM vendor reports, including Inter-Rater Reliability (IRR) assessments, to understand opportunities for improvement.
• Supports internal and external audit and accreditation activities.

Responsible for CMS reporting requirements including:

• Part C Organization Determinations, Appeals, and Grievances (ODAG) report review and auditing for Capital and delegated UM vendors.
• Part C Data Reporting and Validation for Capital and delegated UM vendors.
• Responsible for coordinating results of these audits with the Medicare compliance team.
• Monitors key performance indicators applicable to the UM program. Ensures consistency in criteria application from all UM staff.
• Responsible for Inter-Rater Reliability (IRR) assessments for all UM staff; oversees interventions when performance falls below established thresholds.
• Keeps current with state and federal regulatory activities and accreditation requirements related to utilization review. Assists with education and training of department staff.
• Supports Mental Health Parity and Addictions Equity Act (MPHAEA) UM activities, including Non-Quantitative Treatment Limitations (NQTL) analyses, for internal and vendor-supported functions.
• Performs other related duties and assignments as requested and directed.

Leadership:

• Excellent cross functional collaboration.
• Demonstrated ability to drive results to completion while managing multiple projects and priorities competing for resources.
• Ability to complement leadership and other team members in their responsibilities and roles.

Knowledge:

• Knowledge of health plan regulatory and coverage requirements, including CMS, NCQA, JCAHO, and the DOH.
• Knowledge of the Mental Health Parity and Addictions Equity Act (MPHAEA).
• Knowledge of information technology solutions for health plans, including utilization management and claims payments systems, payment methodologies, and system limitations.

Skills:

• PC literacy and ability to perform electronic research and respond to electronic requests.
• Team oriented attitude with the ability to work and interact with all levels both within and outside of Capital.
• Ability to effectively multi-task under pressure, meet deadlines, and deliver high quality work.
• Demonstrated public speaking and written communication skills; experience in creating and presenting oral and written proposals and presentations; ability to convey complex or technical information in a manner that others can understand.
• Demonstrated organizational and time management skills.
• Self-motivated and works independently; highly accountable.
• Proven problem-solving skills; the ability to systematically analyze problems, draw relevant conclusions, and devise appropriate courses of action.  

Experience:

• Management experience leading teams of staff with varying functions.
• Minimum of (5) years of successful management experience in a healthcare-related field.
• Minimum of (3) years in medical management activities, including UM.

Education, Certification, and Licenses:

• Minimum requirements include a bachelor’s degree in a healthcare-related field.
• Licensure as a health care professional.
• Master’s Degree is preferred.

 

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.    
And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.