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Utilization Management Manager Medical Review

Date:  Apr 8, 2021
Brand:  EyeMed Vision Care
Location: 

Mason, OH, US, 45040

Requisition ID: 356845 
Position:Full-Time
Total Rewards: Benefits/Incentive Information

 

There’s more to EyeMed than meets the eye. EyeMed is the fastest growing managed vision benefits company in the country with consistent double-digit membership growth! Through our commitment to innovation, we’re reimagining the way employers and their employees think about vision care. We want them to see life to the fullest and experience more of what’s best, not more of the same.  And if what’s best hasn’t been done yet, it’s our exceptional and passionate employees driving this change. But, our passion for vision isn’t just about vision insurance benefits. Our employees are proud to support and participate in life-altering global and local missions through our partnership with OneSight, a leading not-for-profit organization with a 100% focus on eradicating the world’s vision crisis.

 

Your family says a lot about who you are. EyeMed is a key member of the Luxottica family of companies, global leaders in the design, manufacture and distribution of fashion, luxury and sports eyewear.  In North America, Luxottica is the home to global brands Ray-Ban, Oakley and many top fashion house brands.  Our leading retail brands include LensCrafters, Sunglass Hut, Pearle Vision, Target Optical and Sears Optical.

 

If you’re passionate about driving innovation and change and interested in a career in the optical and insurance industry, EyeMed wants to start the conversation and help provide you a growth-focused opportunity with America’s fastest growing vision benefits company.

GENERAL FUNCTION

The Manager, Medical Review for Utilization Management (UM) is responsible for collaboration with healthcare providers and members to promote quality member outcomes, member benefit optimization, and effective use of resources. The Manager ensures medically appropriate, high quality, cost effective care by assessing medical necessity of surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting using applicable medical policy and industry standards.

 

MAJOR DUTIES AND RESPONSIBILITIES

  • Manage UM team performance and quality of work
  • Collaborate with management to operationalize system changes and process updates
  • Participate in audits related to credentialing, appeals/grievances, UM, and quality improvement/management; provides necessary documentation for all audit requests
  • Lead UM sub-committee as part of the Quality Improvement Committee (QIC)
  • Oversee internal IRR procedures
  • Collaborate with other departments related to implementation, reporting, and quality improvement
  • Serve as SME for CMS & NCQA guidelines as; provide recommendations for changes to UM policies
  • Maintain UM workplan
  • Conduct pre-certification, concurrent, or retrospective reviews for appropriateness of treatment to maintain compliance with applicable criteria, medical policy, member eligibility, benefits, and contracts
  • Collaborate with providers to assess member needs for early identification and proactive treatment plans
  • Consult with peer clinical reviews and/or medical director to ensure appropriate, high quality, cost effective care
  • Summarize cases for peer clinical reviewers or medical director review using appropriate protocols based on member information
  • Prepare case files for external review
  • Maintain record of the clinical review and determination in the appropriate system
  • Facilitate member care transition through the eye care continuum; refer cases to peer clinical review as required
  • Maintain awareness of industry trends related to UM, vision care quality, and cost efficiency
  • Maintain confidentiality for patient data and provider specific information

 

BASIC QUALIFICATIONS

  • Current, active, unrestricted RN or LPN license issued by a U.S. state(s) or territory
  • 5+ of experience in a related field
  • 2+ years acute care clinical experience.
  • Excellent oral, written and interpersonal communication skills
  • Strong problem-solving, facilitation, and analytical skills
  • Proficient in Microsoft Office
  • Ability to work independently
  • Knowledge of and experience with Medicaid and Medicare regulations
  • Strong organization and multi-tasking skills
  • Demonstrated ability to meet deadlines
  • High sense of urgency
  • Flexible working hours

 

PREFERRED QUALIFICATIONS

  • 5+ years UM experience in managed care, acute, or rehab setting
  • Knowledge of utilization review process and prior authorization process in a managed health care industry
  • Prior supervisory or management experience
  • Prior participation in URAC/NCQA accreditation activities
  • Experience in Project Management

Upon request and consistent with applicable laws, Luxottica will provide reasonable accommodations to individuals with disabilities who need assistance in the application and hiring process.  To request a reasonable accommodation, please call the Luxottica Ethics Compliance Hotline at 1-888-887-3348 or e-mail HRCompliance@luxotticaretail.com (be sure to provide your name and contact information for either option so that we may follow up in a timely manner). 

We are an Equal Opportunity Employer.  All qualified applicants will receive consideration for employment without regard to race, color, gender, national origin, social origin, social condition, being perceived as a victim of domestic violence, sexual aggression or stalking, religion, age, disability, sexual orientation, gender identity or expression, citizenship, ancestry, veteran or military status, marital status, pregnancy (including unlawful discrimination on the basis of a legally protected pregnancy or maternity leave), genetic information or any other characteristics protected by law.  Native Americans receive preference in accordance with Tribal Law.


Nearest Major Market: Cincinnati

Job Segment: Medical, Rehabilitation, Manager, Medicaid, Medicare, Healthcare, Management

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