Lead, Utilization Management (RN)

$91,520 - $91,520/Yr

Evolent Health - Oklahoma City, OK

Full-time - Mid Level

Oklahoma City, OK

Professional, Scientific, and Technical Services

About the position

The Lead Nurse of Utilization Management at Evolent Health is responsible for supervising the operational productivity of the Utilization Management (UM) nurses. This role involves ensuring compliance with regulatory standards, providing guidance to nursing staff, and collaborating with management to enhance staff development and operational efficiency. The position emphasizes leadership, coaching, and fostering a collaborative environment to improve member care and achieve organizational goals.

Responsibilities

• Provides day to day direction, expert operational and system knowledge and operational guidance to nurse staff in the UM department.
• Supports recruitment, interviewing, hiring and the successful onboarding of new UM personnel in collaboration with the Manager and Director.
• Identifies and provides ongoing educational opportunities to staff, ensuring understanding of business processes, technology, health care standards and guidelines.
• Identifies opportunities for training and staff development based on achievement of productivity/quality standards.
• Adjusts workflow responsibilities in line with staff expertise and availability.
• Ensures unit processes, identification and documentation of all health plan program requirements for performance improvement initiatives.
• Assists in developing, implementing and communicating quantitative program actions that substantiate the value proposition and outcomes that effectively support these programs.
• Collaborates with UM Director and Quality Management to develop, implement and maintain UM policy and procedures, standard operating procedures and job aids.
• Works collaboratively across all departments to develop and foster synergistic communication, positive relationships and work processes.
• Participates and leads appropriate unit meetings.
• Respects and maintains HIPAA confidentiality guidelines.
• Acts as an interdepartmental liaison between all Evolent offices, departments, and committees.

Requirements

• Active and unrestricted RN License.
• Associate's degree or equivalent years of work experience.
• 1-2 years of experience working with a global workforce and knowledge of clinical quality metrics such as HEDIS and NCQA preferred.
• 2-4 years of operations and Utilization Management experience in a population management or managed care/insurance or hospital medical management department setting may be substituted for associate degree.
• Experience with clinical decision-making criteria sets (i.e., Milliman, InterQual).
• Strong interpersonal, oral, and written communication skills.
• Basic computer skills.

Nice-to-haves

• Experience in consulting or services organizations with a proven ability to manage client relationships and achieve change within another organization.

Benefits

• Comprehensive health insurance benefits
• Bonus component based on pre-defined performance factors