Job Description

MANAGER, CONCURRENT REVIEW

MCMI IS RESPONSIBLE FOR MANAGING MARYLAND PHYSICIAN CARE’S (MPC) STATEWIDE PROVIDER NETWORK OF HOSPITALS AND PHYSICIANS. MARYLAND PHYSICIANS CARE HAS BEEN PROVIDING SERVICES TO THE HEALTHCHOICE MEDICAID POPULATIONS SINCE 2006 AND IS PROUD TO BE CELEBRATING ITS 25TH ANNIVERSARY. WITH OVER230,000 MEMBERS, MPC CONSISTENTLY HAS BEEN ONE OF THE THIRD LARGEST MANAGED CARE ORGANIZATIONS IN MD. WHILE THE POSITION IS REMOTE, THE INCUMBENT MUST RESIDE IN THE STATE OF MARYLAND AND COMMUTE TO THE LINTHICUM, MARYLAND OFFICE AS NEEDED.

SUMMARY/POSITION OBJECTIVES: This position is responsible for the planning, development, organization, and evaluation of functions for concurrent review programs. Concurrent review is one of the processes within medical management to evaluate while a member is hospitalized the medical necessity of the admission and the appropriateness of the services provided. The process is intended to reduce occurrences of over- under- or misuse of services to improve the member’s inpatient care outcomes and to ensure the cost-effectiveness of the services.

RESPONSIBILITIES:

• Provide oversight of concurrent review process .
• Responsible for recruitment and selection of appropriate staff and prepares timely employee performance evaluations.
• Prepares reports of utilization indicators and activities for committees and senior management.
• Prepares annual budget and operates within approved budget.
• Serves as an active participant in clinical committees such as utilization management, quality management and pharmacy and therapeutics committees.
• Serves as a resource for health plan information and helps to integrate concurrent review function throughout the health plan.
• Assists in the annual development of measurable goals for inpatient utilization review programs based on data form utilization reports, quality indicators, survey results, regulatory agencies and plan initiatives and priorities.
• Implement ongoing development and education of concurrent review staff.

Secondary Functions:

• Communicates regularly with employees through staff meetings to share company, health plan and department information appropriate to their job function.
• Maintains and promotes patient confidentiality and adheres to HIPAA regulations.
• Promotes improved customer service to staff and recognizes their improvement efforts.
• Completes special projects as assigned by management.
• Responsible for development, implementation and annual review of concurrent review policies and desktops.
• Works in a manner that is not disruptive to peers, supervisors and/or subordinates.
• Must maintain regular and acceptable attendance at such level as is determined in the employer’s sole discretion.
• Must be available and willing to work such days and hours as the employer determines are necessary or desirable to meet its business needs.
• Must be available and willing to travel to such locations and with such frequency as the employer determines is necessary or desirable to meet its business needs. (If travel required.)

KNOWLEDGE AND SKILLS:

• Excellent communication skills, both written and verbal.
• Good interpersonal skills including tact and the ability to be a team player.
• Demonstrated skills for presentations and training before small and large groups.
• Knowledge of local health care delivery system.
• Strong problem solving, organizational and time management skills with the ability to work in a fast-paced environment.
• The ability to successfully utilize Microsoft Office suite and common computer and office hardware is necessary.

EDUCATION AND WORK EXPERIENCE:

• CURRENT STATE RN LICENSE
• BACHELOR OF SCIENCE IN NURSING OR HEALTH CARE ADMINISTRATION AND/OR HEALTH RELATED FIELD (BSN PREFERRED). MASTER’S OR MBA PREFERRED.
• THREE TO FIVE YEARS OF PROGRESSIVELY RESPONSIBLE HEALTH CARE ADMINISTRATIVE EXPERIENCE, PREFERABLY WITHIN THE MANAGED CARE INDUSTRY.
• MINIMUM OF FIVE YEARS MANAGEMENT AND SUPERVISORY EXPERIENCE WITH A MINIMUM OF THREE YEARS OF CLINICAL EXPERIENCE.

POSITIONS REPORTING: Concurrent Review Nurse(s)

Company Description

Friendly startup and fast paced environment, schedule flexibility competitive pay