Job Title: Senior Manager, Managed Care Regulatory Filings
Job Responsibilities:
- Execute and successfully complete managed care Utilization Review (UR) filings by state.
- Maintain standards for the URAC accreditation and handle onsite or virtual validation reviews or audits.
- Monitor the timeliness of UR determinations in daily/monthly reporting for compliance with jurisdictional requirements.
- Conduct research on state Utilization Review regulations to ensure compliance and accuracy.
- Track and analyze trends in treatment services processed in UR.
- Serve 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 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 respond to corporate UR complaints or questions from regulators.
Education and Experience Information:
- A college degree with a major in Political Science, Economics, English, Nursing, or Philosophy is required.
- 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 is necessary.
- Previous experience in maintaining URAC accreditation is preferred.
- Experience in quality assurance and audits is required.
- Experience in Paralegal research and submissions is advantageous.
Skills and Knowledge Requirements:
- 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 schedules 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:
- Consideration will be given to reasonable accommodations when applicable and appropriate.
- Mental requirements include clear and conceptual thinking ability, excellent judgment, troubleshooting, problem solving, analysis, and discretion. The ability to handle work-related stress, multiple priorities simultaneously, and meet deadlines is essential.
- 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.
Additional Information:
- The company strives to create a diverse and inclusive culture where thoughts and ideas of all employees are appreciated and respected.
- The company values diversity, seeing it as integral to maintaining a competitive advantage and remaining an employer of choice.
- Diversity is considered more than just policies and practices; it is integral to the company's identity, operations, and future vision.
