Job Title: Senior Manager, Managed Care Regulatory Filings
Job Responsibilities:
- Responsible for the execution and successful completion of company UR filings by state.
- Maintain all standards for URAC accreditation and oversee any onsite or virtual validation reviews or audits.
- Monitor the timeliness of UR determinations in daily/monthly reporting to ensure compliance with jurisdictional requirements.
- Conduct research on state Utilization Review regulations.
- Track and trend treatment services processed in UR.
- Act as the liaison with regulatory and accrediting agencies for managed care UR filings.
- Oversee workflows to ensure they meet all state regulations.
- Maintain and coordinate all filings, resubmissions, and UR data calls as necessary.
- Assist in the development and implementation of the Utilization Review program, including jurisdictional research, policies & procedures, workflows, vendor management, and UR correspondence.
- Collaborate with Claim Legal, Regulatory, and Compliance departments to address corporate responses to any UR complaints or questions from regulators.
Education and Experience Information:
- College degree with a major in Political Science, Economics, English, Nursing, or Philosophy.
- Previous experience in creating and submitting managed care and/or Utilization Review state filings is preferred.
- Moderate knowledge of Workers Compensation Utilization Review requirements by jurisdiction and accrediting bodies.
- Previous experience in maintaining URAC accreditation is preferred.
- Experience in quality assurance and audits.
- Experience in paralegal research and submissions.
- Utilization Review experience is required.
Skills & Knowledge:
- Knowledge of workers' compensation laws and regulations.
- Excellent oral and written communication skills.
- Advanced computer skills, including proficiency in Microsoft Products.
- Advanced time management skills to maintain state filing schedule for resubmissions.
- Ability to interact collaboratively and work effectively with a multi-functional team and throughout the organization.
- Strong organizational skills.
- Excellent interpersonal and negotiation skills.
- Ability to work in a team environment.
- Ability to meet or exceed performance competencies.
- Experience with state and external accreditation managed care audits and reviews.
- Ability to collaborate across functional lines and leaders.
- Strong communication skills.
Work Environment:
- When applicable and appropriate, consideration will be given to reasonable accommodations.
- Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem-solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines.
- Physical: Computer keyboarding.
- Auditory/Visual: Hearing, vision, and talking.
Salary Information:
While specific salary information is not provided, the company offers a competitive compensation package and excellent career advancement opportunities.
Additional Information:
The company offers a range of benefits, including Medical & Dental Plans, Life Insurance (including eligible spouses & children), Health Care Flexible Spending, Dependent Care, 401k Savings Plans, and Paid Time Off.
The company is committed to creating a diverse and inclusive culture where the thoughts and ideas of all employees are appreciated and respected. This includes, but is not limited to, human differences with regard to race, ethnicity, gender, sexual orientation, culture, religion, or disabilities. Diversity is considered a business imperative, enabling the company to attract, retain, and develop the best talent available.
