Job Title: Senior Manager, Managed Care Regulatory Filings
Job Responsibilities:
- Execute and successfully complete company Utilization Review (UR) filings by state.
- Maintain standards for URAC accreditation and manage onsite or virtual validation reviews or audits.
- Monitor timeliness of UR determinations through daily/monthly reporting for 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 processes meet all state regulations.
- Maintain and coordinate all filings, resubmissions, and UR data calls as necessary.
- Assist in developing and implementing the Utilization Review program, including jurisdictional research, policies & procedures, workflows, vendor management, and UR correspondence.
- Collaborate with Claim Legal, Regulatory, and Compliance departments to respond to any UR complaints or questions from regulators.
Education and Experience Information:
- A 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.
Skills and Knowledge:
- Utilization Review experience is required.
- 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 and excellent interpersonal skills.
- Excellent negotiation skills.
- Ability to work in a team environment and 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:
- Consideration for reasonable accommodations when applicable and appropriate.
- Mental requirements include clear and conceptual thinking ability, excellent judgment, troubleshooting, problem-solving, analysis, discretion, ability to handle work-related stress, ability to handle multiple priorities simultaneously, and ability to meet deadlines.
- Physical requirements include computer keyboarding.
- Auditory/Visual requirements include hearing, vision, and talking.
Salary Information:
The company offers a competitive compensation package and excellent career advancement opportunities. Benefits include Medical & Dental Plans, Life Insurance (including eligible spouses & children), Health Care Flexible Spending, Dependent Care, 401k Savings Plans, and Paid Time Off.
Diversity and Inclusion:
The company strives to create a diverse and inclusive culture where thoughts and ideas of all employees are appreciated and respected. This encompasses but is not limited to human differences regarding race, ethnicity, gender, sexual orientation, culture, religion, or disabilities. The company values excellence and recognizes that embracing diverse backgrounds, skills, and perspectives will sustain a competitive advantage and remain an employer of choice. Diversity is seen as more than just policies and practices; it is an integral part of who the company is, how it operates, and how it envisions its future.
