Utilization and Case Management Manager

  • Aids Healthcare Foundation
  • Fort Lauderdale, FL , United States
  • Jan 05, 2018
Full time Case Manager Nurse Registered Nurse

Job Description


Includes the following.  Other duties may be assigned.

Responsible for the direction of Utilization and Case Management Departments; Maintains adequate functionality and effective administration of departments; Coordinates staff schedules to assure effective functioning of programs.

Implements and evaluates Utilization Management and Case Management policies and procedures, guidelines and action plans in compliance with all state/federal and/or Medicare/Medicaid requirements.

Monitors and evaluates the performance of Case Management and Utilization Programs through activity reports to assure appropriate delivery of health care services and adherence to regulatory and contractual requirements; ensures that the Utilization Management and Case Management Programs are compliant with state/federal and/or Medicare/Medicaid specifications for Managed Care Programs.

Participates in the development, implementation, and oversight of specialty programs and/or expense programs; Analyzes performance of programs against AHF MCO goals, industry standards and contractual performance guarantees.

Conducts utilization and site audits required to meet regulatory and contractual obligations.

Forecasts and develops plans for departmental allocation of resources; Assists in the development of departmental budgets; Maintains budget; Prepares monthly variance reports with corrective actions.

Develops, monitors and analyzes key program indicators in the areas of utilization and quality; Takes corrective action as necessary.

Coordinates lines of communication between Utilization and Case Management staff, Disease Management and Executive Management.

Participates in provider relations and contracting activities as necessary to maintain and develop AHF MCO Contracted Provider Networks.

Administers Utilization Management Referral, Prior Authorization, grievance and appeal processes, working closely with the Plan Medical Director to ensure compliance to AHF MCO timeframes for action and notification.

Coordinates Utilization Management and Case Management Committee agenda; Provides quality indicator reports and report analysis to committee members and Executive Management.

Provides administrative clinical oversight to Medical Claims Department and works with them to maintain clear lines of communication and effective processes for prospective, concurrent and retrospective review of services provided and paid. 

Participation in AHF Meetings/Committees
Attends AHF MCO meetings as assigned.
Attends Utilization Management and Case Management Committee Meetings.
Chairs Committees as assigned.

Supervisory Responsibilities
Carries out supervisory responsibilities in accordance with AHF MCO policies and applicable laws.  Responsibilities include interviewing, hiring, and training employees;  planning, assigning and directing work, appraising performance;  rewarding and disciplining employees;  addressing complaints and resolving problems. 


To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.    The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience
Graduate from an accredited RN Program with 3 or more years of recent medical/surgical or HIV/AIDS nursing experience and 3 or more years of recent Utilization Review/Case Management experience.

Computer/Software Skills & Abilities
To perform this job successfully, an individual should have knowledge of Contact Management systems, Word processing software, and Spreadsheet software.

Language Skills
Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents.  Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community.  Ability to write speeches and articles for publication that conform to prescribed style and format.  Ability to effectively present information to top management, public groups, and/or boards of directors.

Mathematical Skills
High Skills:  Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry.  Ability to apply concepts such as fractions, percentages, rations, and proportions to practical solutions.

Reasoning Ability
Very High Skills:  Ability to define problems, collect data, establish facts, and draw valid conclusions.  Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables

Other Skills & Abilities/Qualifications
Ability to successfully work with various levels of professional staff
Must be able to work independently and as part of a team.
Knowledge of HIV/AIDS and related medical and patient care issues and concerns in diverse populations.

Certificates, Licenses and Registrations
Current Florida RN License



DISCLAIMER: We at AIDS Healthcare Foundation believe that each individual is entitled to equal employment opportunities without regard to race, color, creed, gender, sexual orientation, gender identity, marital status, national origin, age, veteran status or disability. The right of equal employment opportunity extends to recruiting, hiring selection, transfer, promotion, training and all other conditions of employment.


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