The Utilization Management Supervisor - Pre-Service leads a team of utilization review nurses that are responsible for supporting Bright’s Pre-Service Function. The department activity may involve intake referral processing, provider coordination and authorization and/or completion of the eligibility, benefits, and authorization process. The Supervisor will monitor performance of the team and individual members and takes appropriate action to ensure department goals are met and that staff are utilizing appropriate guidelines to make medical necessity decisions. This individual will serve as a role model for team members, assuring both members and providers have a positive experience with the services they receive. The Supervisor position will provide guidance, training, and oversight to a group of utilization review nurses directly and ensure the team is working to achieve expected clinical outcomes. The Supervisor-Pre-Service ensures all related initiatives meet all applicable state and/or federal regulatory requirements in addition to corresponding URAC standards.

ROLE RESPONSIBILITIES

• Provide leadership and direction to a team of Utilization Management review nurses inclusive of training and performance oversight.
• Support staffing and scheduling plans to meet departmental objectives as provided by leadership, including meeting specified service levels.
• Monitor operational key performance indicators to track service delivery against targets. Audit staff members to ensure compliance.
• Assist in recruiting, hiring, and training new team members.
• Enforce UM policies and procedures to ensure compliance with state and federal agencies as well as accreditation standards.
• Support the development and maintenance of standard operating procedures related to corresponding program functions.
• Participate in the development of operating models to execute utilization management solutions.
• Assist in the preparation with all applicable audits pertaining to utilization management.

SUPERVISORY RESPONSIBILITIES

This position has supervisory responsibilities for members of the Utilization Management Pre-Service team.

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• A minimum of an associate degree in Nursing required.
• Three (3) or more years of Supervisor experience within a consumer support function
• Two (2) or more years of healthcare related experience
• Awareness and experience with HIPAA requirements for healthcare communication
• Prior experience with URAC accreditation is desired, but not required
• Formal training in Six Sigma management techniques is desired, but not required

PROFESSIONAL COMPETENCIES

• Approaches challenges calmly and objectively to identify the best solution
• Capable communicator that can interact with others at multiple levels within the organization, customers and providers
• Leads through influence and example
• Strong operational mindset and uses data to draw insights
• Thrives on driving results in a collaborative environment

LICENSURES AND CERTIFICATIONS

An active, Registered Nurse (RN) or Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN) license to practice as a health professional in a state or territory of the United States is required for this role.

WORK ENVIRONMENT

The majority of work responsibilities are performed in a remote home office carrying out responsibilities sitting/standing at a desk/table and working on the computer. Travel is not required.

For individuals assigned to a location(s) in California, Bright Health is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant’s education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $74,419.56-$111,629.33 Annually.

Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; up to 21 days of PTO, 10 paid holidays, plus 2 floating holidays per year; and a lifestyle spending account.