Candidates must be a resident of New Mexico to be considered for this role.

Who is Comagine Health?

Comagine Health is a national, nonprofit, health care consulting firm. We work collaboratively with patients, providers, payers, and other stakeholders to reimagine, redesign and implement sustainable improvements in the health care system.

As a trusted, neutral party, we work in our communities to address key, complex health, and health care delivery problems. In all our engagements and initiatives, we draw upon our expertise in quality improvement, care management, health information technology, analytics, and research.

We invite our partners and communities to work with us to improve health and redesign the health care delivery system.

• Provide operational management of clinical staff who provide utilization review, and/or specialty reviews.
• Develop, implement, and maintain departmental policies and procedures, staffing protocols, training programs, quality management programs, and department budgets.
• Ensure that department fully meets all required legal, contractual and accreditation standards as well as compliance with corporate policies.
• Participate in business/product development, proposals and customer relations activities.
• May also conduct prospective, concurrent, and/or retrospective utilization management reviews.

• On a formal and informal basis, conducts performance appraisals with staff using objective data related to job performance and goals/standards established for each position
• Ensures that all resource materials, such as reference books, computers, provider manuals, internet connectivity, etc., necessary to conduct daily work activities are made available to staff
• Ensures that established quality, productivity and attendance standards are met by all staff through regular performance monitoring
• Develops, updates and shares job descriptions with staff to clarify job expectations and performance standards
• Initiates timely and appropriate counseling, education, training and coaching with staff to support professional development or to address areas of performance deficiencies and related improvement expectations
• Responsible for all personnel management activities, including supervision, evaluation, hiring and termination, in accordance with company policies and under advisement of management
• Serves as a consultant to staff regarding clinical and/or non-clinical matters, customer expectations, accreditation standards, contractual requirements and utilization activities, as applicable

Ensures the integrity and high quality of utilization management services

1. Accepts utilization management assignments when work volumes or case complexities require managerial back up
2. Collaborates with the development and implementation of a quality management program, including an on-going internal quality control (IQC) system that provides on-going performance monitoring for compliance with contractual requirements, performance measures accreditation standards
3. Collaborates with medical affairs and staff in developing guidelines and protocols for clinical review staff in referring, consulting, and staffing cases/reviews with Medical Directors and physician/practitioner consultants and dentists.
4. Develops and implements, through collaboration with staff and other managers, the necessary operational policies and procedures to meet contractual requirements, customer expectations, accreditation standards, and organizational needs
5. Monitors and maintains adequate access by providers, customers, patients/clients, and others with staff in order to provide the timely provision of Utilization Review services
6. Reviews Utilization Review reports, appeal letters, and other sensitive documents to ensure they meet contractual requirements, accreditation standards, performance measures, timeframe requirements, and service standards %

Efficiently and effectively manages financial responsibilities

1. Develops and monitors the productivity standards for the staff to ensure there is efficient and effective delivery of services by the appropriate number and skill level of staff
2. Develops timely and appropriate budgets that include sufficient staffing and other resources to meet the contractual requirements, case/review volumes, service standards, and organizational goals
3. Ensures compliance with finance and accounting policies and procedures, which includes but is not limited to the delegations of authority
4. Initiates timely and appropriate managerial interventions to improve compliance with the budget when expenditures are not in line with budget
5. Monitors unbilled hours and open cases/reviews to ensure that there is timely, accurate, and appropriate billing by staff

Effectively works with customers, including business development activities

1. Participates in responses to requests for proposals (RFPs), product development, and other business development activities
2. Promotes, monitors, and improves positive customer service behaviors, communications, and attitudes by all staff in the provision of services to all stakeholders
3. Provides timely, appropriate, and responsive communications and interventions when necessary with providers, patients/clients, customers, and other stakeholders to resolve their concerns, questions, and issues
4. Represents the products/services of the department through the active participation in customer conference calls, customer meetings, and educational seminars

Complies with policies and procedures, administrative assignments and other projects

1. Develops, monitors, and reports on departmental goals, standards, and objectives through collaboration with the Vice President, Medical Director, Operations Director, staff, and other managers
2. Ensures that the Vice President, Operations Director or designee is informed in a timely manner regarding significant operational issues, performance measures, complaints/grievances, compliments, quality management initiatives, staffing concerns, and other relevant topics
3. Maintains compliance with organizational policies and procedures, including but is not limited to the strategic plan, organizational structure, confidentiality, safety, and complaint/grievance resolution
4. Monitors completion of timecards to ensure staff's accuracy, timeliness, and compliance with related policies and procedures

Compensation Range: $85,000 - $107,000

• Intermediate MS Office Suite proficiency
• Working knowledge of Medicaid, or commercial insurance preferred

• Current, active, unrestricted RN licensure
• BA / BS in a related field
• Equivalent combination of education and/or work experience may be substituted
• IQCI or certification in a medical management field preferred
• At least 5 years of utilization/case management experience
• At least 2 years of management experience, including financial management