p>Preferred Qualifications: ā¢ Experience in clinical practice with a focus in appeals & grievances, claims processing, utilization review or utilization management/case management ā¢ Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines ā¢ Extensive experience in healthcare appeals ā¢ MBA or master's degree from an accredited institution with focus in training & development, education, business, or healthcare administration ā¢ Management experience in an operational department within the healthcare industry focused on clinical leadership ā¢ Leadership experience in a focus area of operational excellence or audit ā¢ Experience developing strategy and processes for a department or function ā¢ Experience managing vendors as an extension of a core team ā¢ Familiar with creating accountable ownership of a vendor team.
Minimum Qualifications:
ā¢ Bachelor's degree from an accredited institution or equivalent work experience ā¢ RN ā¢ Experience with utilization management or appeals and grievance processing and compliance ā¢ Working experience in a fast-paced environment overseeing multiple priorities, tasks and/or teams ā¢ Proven track record of exercising independent thinking, ability to problem solve, understand process flows and correlating platforms to recommend and implement solutions ā¢ Experience preparing and delivering written and verbal information to multiple types of audiences ā¢ Demonstrated ability to build and foster effective relationships.