ProMedica Health System ADR / DUR Manager -HMS- Full Time - Days in Columbus, Ohio
At Paramount, we offer insurance to both large and small groups and also cater to Medicare (Paramount Elite) subscribers in northwest Ohio and southeast Michigan. Our Medicaid product (Paramount Advantage) services those living in the state of Ohio. We maintain an accreditation by the NCQA – the National Committee for Quality Assurance – for our Ohio HMO, Elite and Advantage products. We’re also part of ProMedica, which is ranked the second most integrated health system in the U.S. and No. 1 in the Midwest.
Our mission is to improve your health and well-being. So we’re committed to your wellness with various initiatives, such as preventive services, online knowledge, health risk assessments, our Steps2Health disease management programs, health fairs, and more.
ADR/DUR Manager supervises one RN and three non-clinical ADR/DUR Coordinators.
The ADR/DUR Manager is responsible for the coordination of daily operations and clinical oversight of Drug Utilization Review (DUR) and Alternate Dispute Resolution (ADR) activities and employees. Provides routine quality assurance activities to ensure continued process improvement and provides clinical oversight to the ADR/DUR team. Assists in the overall quality assurance initiatives as related to these services. Complies with all company and BWC requirements for the DUR and ADR functions. Assures timely processing of DUR requests, MCO appeals and ensures appropriate care and case management processes are followed within the handling of the DUR and ADR processes, and handles overflow when needed. Operates within the scope of practice for RN licensure in Ohio. Contributes to the clinical operation of the MCO Utilization Management (UM) and Care Management (CM) when needed.
Demonstrates knowledge of medical, quality and care/case management principles in addition to related state, federal and other regulatory requirements associated with these activities.
Participates in the implementation and monitoring of medical and quality management policies and procedures that support the CM standards of practice and the URAC Core standards. Participates as a member of the Quality Committee. Conducts effective and timely performance evaluations and takes firm steps to address poor performance. Processes payroll and other employee management related documents.
Assists with coordinating, implementing, evaluating and reporting CM and quality initiatives, including quality improvement projects. Assists with URAC reaccreditation and company audits. Monitors and evaluates MOD cases.
Demonstrates the ability to effectively manage and provide support and coaching to assigned staff to attain operational goals. Provides leadership and support for team functions inclusive of preparation for employer meetings and claims reviews. Travels to meet with clients at their facilities to conduct claims review meetings, presentations, and is available for conference calls with clients. May provide community based health services.
Routinely assesses, monitors, evaluates and reports data and performance outcomes to assist with effectively managing processes and performance. Performs audit functions, reports audit outcomes, investigates audit variances and recommends actions steps, as needed. Demonstrates ability to implement new projects in a methodical, organized manner, and integrates department function with corporate function to support corporate goals.
Oversees the DUR and ADR department and monitors and evaluates the internal DUR and ADR processes, both clinically and administratively as needed, while demonstrating the ability to plan and implement change. Maintains patient and provider confidentiality. Pursues individual expertise and job growth, expanding knowledge base as evident by maintaining professional licensure and obtaining CEUs.
Assist and coordinate internal staff activities and trainings to ensure timeframes and deliverables are met regarding patient medication safety.
Responsible for prescriber contact regarding medication safety issues when identified during claim file reviews.
Education: Minimally an associates from an accredited school of nursing
Skills: Strong working clinical knowledge of medications, understanding and interpretation of the American Geriatrics Beer’s Criteria and identifying patient medication safety issues, and strong interpersonal and computer skills required.
Years of Experience: 3 years acute clinical experience required
License: current unrestricted Ohio Registered Nurse Licensure
Education: Bachelor’s Degree from an accredited school of nursing.
Skills: Previous supervisory/management experience as well as strong working knowledge of the Ohio Bureau of Workers’ Compensation system.
Certification: Obtain a certification in case management from the URAC-approved list within three (3) years of date of hire.
Personal Protective Equipment: N/A
Physical Demands: N/A
The above list of accountabilities is intended to describe the general nature and level of work performed by the incumbent; it should not be considered exhaustive.
Requisition ID: 52794