Supervisor, Utilization Management

**Profile** ----------- We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI \& WY only). Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Veterans, Reservists, Guardsmen and military family members are encouraged to apply! **Job Summary** Supervises daily Utilization Management (UM) program operations. This position reports to a Manager of Utilization Management in either Prospective, Retrospective, or Appeals and Reconsideration for the TRICARE contract. The supervisor coordinates across teams to support meeting contractual metrics and timeliness, standardized clinical care requirements and accreditation standards. This position is responsible for supervision of UM performance and staff management. Development and preparation of operational reports. Functions as backup for staff during high volume periods. **Education \& Experience** **Required:** * Registered Nurse, with current valid, unrestricted nursing license * 3\+ years of job related experience in a healthcare environment * 3\+ years supervisory or leadership experience in a healthcare environment * 2\+ years utilization review or case management * U.S. Citizenship * Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation **Preferred:** * Medical/Surgical or Behavioral Health experience * Commercial Managed Care experience * Knowledge of government health care programs * Familiarity with utilization review criteria * CCM or HCQM certification * Knowledge of medical billing and coding * Prior experience with remote work environments **Key Responsibilities** * Supervises day to day UM operations to ensure operational effectiveness and efficiency. * Ensures staff is fully\-informed of changes by communicating updates, policy revisions, performance outcomes, and significant events. * Prepares work schedules and monitors staff caseloads to ensure adequate staffing levels at all times and accurate data entry and application of the medical management system. * Monitors staff to ensure adherence to established criteria, including InterQyal, internally developed guidelines, decision support tools, contract requirements and TriWest policies and desk procedures. * Prepares reports for tracking and trending of UM activities. * Interprets reports and identifies UM opportunities to share with management. * Monitors the UM process and identifies and implements process improvements to ensure program quality assurance and compliance. * Reports Potential Quality Issues (PQI). * Responsible for interviewing and hiring new staff. * Provides coaching and oversight to staff to ensure staff success and development. * Assists with implementation, orientation and training of new staff. * Assists with the development of desk proce