Hybrid Utilization Review Program Manager bei Davies
Davies · Orlando, Vereinigte Staaten Von Amerika · Hybrid
- Professional
- Optionales Büro in Orlando
Our Story
Imagine being part of a team that’s not just shaping the future but actively driving it. At Davies North America, we’re at the forefront of innovation and excellence, blending cutting-edge technology with top-tier professional services. As a vital part of the global Davies Group, we help businesses navigate risk, optimize operations, and spearhead transformation in the insurance and regulated sectors.
We are seeking an experienced Utilization Review (UR) Program Manager to lead our Utilization Review team and ensure compliance with statutory regulations, URAC standards, and organizational quality objectives. This role is ideal for a results-driven leader with deep knowledge of Workers’ Compensation and utilization management processes.
Key Responsibilities
- Provide direct leadership to Utilization Review RN Specialists and the Medical Bill Review Nurse, ensuring compliance with AmeriSys policies, procedures, and performance expectations.
- Oversee all UR unit operations, including proactive leadership, performance management, and personnel-related matters in coordination with HR.
- Facilitate case conferences with adjusters and/or Telephone Case Managers to address case concerns and evaluate the appropriateness of UR referrals.
- Direct and perform retrospective utilization management activities in accordance with state bill review guidelines and AmeriSys protocols.
- Audit complex medical bills for service utilization, medical necessity, and appropriateness of charges.
- Lead advanced negotiations on high-dollar medical bills in conjunction with the Assistant Vice President and the Medical Bill Review Nurse.
- Maintain strong relationships with state workers’ compensation departments by applying expert knowledge of bill review rules, conducting thorough research, and delivering timely, accurate responses.
- Supervise comprehensive medical record reviews, prepare chronological medical summaries, and ensure documentation accuracy.
- Uphold and enforce all URAC Workers’ Compensation Utilization Management accreditation standards.
- Coordinate with Peer Physicians by posing relevant case questions, reviewing their reports, and delivering final recommendations to adjusters and/or TCMs.
- Follow up with claims staff to determine the need for further explanation or additional services.
- Compile and present monthly and quarterly QA/UR meeting minutes, ensuring all related functions are documented.
- Ensure timely responses to all grievances and disputes per AmeriSys policies.
- Safeguard patient privacy and confidentiality in compliance with state and federal regulations.
- Prepare and present required materials for URAC audits.
- Communicate regularly with AmeriSys management regarding operational issues or concerns.
- Manage special projects and perform additional duties as assigned.
Skills, knowledge & expertise
- Registered Nurse (RN) with current state licensure (California nursing license preferred).
- Minimum 3 years of healthcare management experience, preferably in Workers’ Compensation.
- Minimum 3 years of diverse clinical experience in specialty areas such as ER, ICU/CCU, Surgery, Trauma, Orthopedics, Neurology, or Psychiatry.
- At least 2 years of Utilization Review experience in Workers’ Compensation, Health & Accident, or Auto Liability.
- Certification in Utilization Review (CPUR, ABQUARP) preferred.
- Active membership in a local Utilization Review organization preferred.
- Proven ability to lead, coach, and develop a team while fostering a collaborative and engaged work environment.
- Skilled in setting performance goals, monitoring outcomes, and ensuring minimal turnover.
- Demonstrated ability to use a coaching, affiliative, and democratic leadership style to maintain respectful and productive team interactions.
- Proven ability to lead, coach, and develop a team while fostering a collaborative and engaged work environment.
- Skilled in setting performance goals, monitoring outcomes, and ensuring minimal turnover.
- Demonstrated ability to use a coaching, affiliative, and democratic leadership style to maintain respectful and productive team interactions.
- In-depth knowledge of Workers’ Compensation laws and their integration into Managed Care programs and AmeriSys Medical Management Standards
- Strong understanding of URAC Workers’ Compensation Utilization Management standards.
- Proficiency in personal computers, claims systems, and business software, including Microsoft Office Suite.
- Ability to stay current with industry trends, standards, and law changes.
- Proven ability to lead, coach, and develop a team while fostering a collaborative and engaged work environment.
- Skilled in setting performance goals, monitoring outcomes, and ensuring minimal turnover.
- Demonstrated ability to use a coaching, affiliative, and democratic leadership style to maintain respectful and productive team interactions.
- Exceptional verbal and written communication skills.
- Strong customer service orientation and ability to build relationships with internal and external stakeholders.
- Highly organized, self-directed, and able to work independently with minimal supervision.
- Excellent attendance, reliability, and professionalism.
Benefits
Benefits
At Davies North America, we are dedicated to supporting the well-being and future of our qualifying employees. Our comprehensive benefits package includes:
- Medical, dental, and vision plans to ensure your health and that of your family.
- A 401k plan with employer matching to help you build a secure financial future.
- Our time-off policies, including Discretionary Time Off for exempt employees and Paid Time Off (PTO) package for non-exempt employees, reflect our commitment to promoting a healthy work environment.
- Paid holidays.
- Life insurance and both short-term and long-term disability plans, providing essential financial protection for you and your loved ones.
Diversity and Inclusion
Davies is dedicated to fostering a diverse and inclusive workplace that embraces a wide range of perspectives and experiences. We believe that diversity of thought is essential for innovation and creativity, and we actively promote an environment where all voices are valued and heard.
