A person in this role is responsible for utilization review quality assurance and mentorship to equip operations with tools and processes for consistent delivery of CorVel's utilization review as follows:
- Develop, implement and provide ongoing quality assurance calibration of processes both managed and delivered at the operational level.
- Develop and implement a utilization review mentoring process both managed and delivered at the operational level.
- Educate and equip operations with performance measurement and reporting tools that can be used to objectively measure and grow operations.
- Provide national account and regulatory quality oversight.
- As applicable, provide oversight and management of URAC compliance and renewals.
CorVel is a national provider of industry-leading risk management solutions for the workers' compensation, auto, health and disability management industries. CorVel was founded in 1987 and has been publicly traded on the NASDAQ stock exchange since 1991. Our continual investment in human capital and technology enable us to deliver the most innovative and integrated solutions to our clients. We are a stable and growing company with a strong, supportive culture and plenty of career advancement opportunities. Over 3,500 people working across the United States embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).
A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:
- Work with executive, general and utilization review department management to ensure the utilization review department has implemented and is following CorVel standards inclusive of quality assurance, reporting and management processes.
- Work closely with future talent acquisitions to ensure the consistent full implementation and training of all utilization review managers to CorVel standards, utilization review and report system usage.
- Identify and participate in training and developmental needs of the utilization review leadership and including the training /re-training of all offices on standards and procedures, including usages of the CorVel utilization review and reporting system.
- Develop, run and interpret management reports to ensure the utilization review operations are utilizing the tools available to manage compliance of services delivery within company standards.
- Facilitate peer-to-peer quality reviews to ensure delivery of quality utilization review.
- Review results and outcomes with general management and utilization review leadership and develop action plans where warranted.
- Make recommendations in collaboration with field operations to ensure action toward improvement have been identified. Measurement and compliance with these actions are the responsibility of the field.
- Develop and oversee utilization review manager mentor program to facilitate the onboarding of new supervision and management to equip field with the tools for compliance and consistency of CorVel standards and procedures.
- Implementation, oversight and communication of regulatory requirements within utilization review services to include, state, federal and URAC.
- Identify trends and recommend action plans to management for continuous process improvement.
- Performs other duties as assigned.
- Ability to travel up to fifty percent of the time.
KNOWLEDGE & SKILLS:
- Excellent oral and written communication skills.
- PC literate, including Microsoft Office (Word, Excel).
- Strong knowledge of the clinical and case management processes.
- Strong knowledge and experience in quality assurance and training programs.
- Proficient in identifying utilization review office improvement opportunities and communicating and implementing solutions.
- Ability to remain poised in stressful situations and communicate diplomatically via telephone, computer, fax, correspondence, etc.
- Ability to skillfully manage multiple, complex projects and competing priorities concurrently while working under pressure to meet deadlines and maintaining strong customer service orientation.
- Effective quantitative and analytical skills.
- Must have strong organizational skills.
- Ability to work independently or in a team environment while functioning as an educator rather than an auditor.
- Knowledge of the entire claims administration, utilization review and cost containment solution as applicable to third party administrator operations.
- Graduate of accredited school of nursing with a diploma/Associates degree (Bachelor of Science degree or Bachelor of Science in Nursing preferred).
- 3 or more years of recent clinical experience, preferably in rehabilitation.
- National certification (CRC, CIRS, CCRN, CVE, CCM, etc.), CCM preferred.
- Four year degree at an accredited college or university preferred.
- Certified Trainer and/or Quality Assurance distinction, a plus.
- Current RN licensure.
- Four (4) years of utilization review experience preferred or equivalent experience.
- Workers' compensation and prior quality assurance and/or training a plus.
- Working knowledge of URAC Standards.
FIRST YEAR SUCCESS MEASUREMENTS:
- Utilization Review Services Revenue Improvement in Enterprise Comp, Managed Care and Carrier markets.
- Establish Baseline of Quality Measurements in Utilization Review Services.
- Increase Quality Management.
- Retention of Existing Customers and Services.
- Approval by URAC for Applicable Services.
- Establish and Implement a Mentor Team and Program.