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