This position leads the Health Services and Health Hotline departments in meeting and exceeding established utilization goals, directing improvements and innovations within those departments to support Hometown Health´s and Renown Health´s purpose.
The position is responsible for:- Ensuring compliance with state and governmental regulations as well as knowledge in the benefit structure of all Hometown Health product lines. - Effectively coordinating optimal utilization of resources for Hometown Health members while maintaining a positive relationship with providers. - Directing the coordination of activities with Hometown Health and the Pharmacy Benefit Manager, while identifying areas for improvement. - Actively participating in the development of company policies as it affects the community, our partners and our customers. The position is accountable for all departmental budgets and any variances associated with it. In addition, having the authority to hire, counsel, provide educational opportunities for staff, evaluate and terminate employees as outlined in the Renown human resources policies. The position is active in collaborating with Provider Relations, Customer Services, Reimbursement Services and Quality departments to contribute providing optimal services to our members. Minimum Qualifications:Education: Bachelors Degree is required. Masters degree in nursing, health science or business preferred.Experience: Five years clinical experience including any combination of acute and non-acute care is required. Three years utilization review, case management and/or managed care experience and three years of experience in a managerial position is required.License(s)/Certification(s): Current valid Nevada RN license required. Case Management and/or Quality Management Certification preferred.