| Job Category : | Management |
| Company Name: | Aflac, Incorporated |
| Position Name: | Mgr, Utilization Mgmt |
| Location : | Florida |
| Job Description : | Job Summary Provide management and oversight of the UM department to ensure accurate, timely and efficient processing of all pre-service authorization requests for the dental and vision team of reviewers; accountable for the delivery of a UM team performance that aligns with all CMS guidelines and health plan agreed-upon initiatives, policies, and turnaround times Principal Duties & Responsibilities Responsibility for the operational performance of the UM dental and vision teams Oversee regular monitoring and reporting of the UM team’s performance to include the UM supervisor, reviewers, and coordinators; report weekly, monthly, and quarterly SLAs or KPIs, including forecasting if goals will not be met Create, implement, and maintain UM department policies and procedures to ensure all criteria set by Medicare/Medicaid and each specific health plan are adhered to Work with the Supervisor(s) to oversee daily production including assistance with assigning daily workload to UM reviewers and coordinators Participate in and provide insight during meetings with other department heads to ensure departments are able to work seamlessly with each other Provide any documentation or reporting on UM department as requested by the health plans including but not limited to escalations, inquiries, audits, ad hoc reports, and RFPs Collaborate with UM team, Medical Director and Dental Director for training – initial, annual, and ongoing; create and maintain training records, desktop procedures and UM processing guides Provide regular and ongoing processing quality auditing of the UM team, including SOC2; assist in pre-delegation and annual delegation audits by maintaining audit tools, file selections and attending any desktop or web-based audit; assist in any related corrective action plans, if needed Liaise with and report UM-related issues to the Argus technology team including reporting errors, server outages, system configuration and user problems Perform other duties as necessary Education & Experience Required Bachelor’s Degree in Business Administration or a related field Five years of experience un healthcare utilization management or claims processing Three years in a leadership/senior/supervisory capacity in a diverse work environment Or an equivalent combination of education and experience Education & Experience Preferred Dental and Vision background Job Knowledge & SkillsMedicare or Medicare health plan or TPA experience Specialization or certification as a dental or ophthalmic technician with practice-level experience Extensive knowledge of specialty language, practice patterns and acronyms as well as billing and coding knowledge Knowledge and understanding in benefit descriptions to assess coverage Excellent written and communication skills Demonstrated high level of written, verbal, and interpersonal communication skills Ability to work as part of a team and independently Competencies Acting with Integrity – Clearly states goals and beliefs; lets people know his/her true intentions; does what he she said they would do; follows through on commitments Communicating Effectively – Expresses ideas and information in a clear and concise manner; tailors message to fit the interests and needs of the audience; delivers information in a manner that is interesting and compelling to the listener Pursuing Self-Development – Demonstrates ambition and desire to move forward in his/her career; engages others in discussions about career development; seeks feedback on ways to increase his/her performance; takes advantage of opportunities to build new skills and capabilities Serving Customers – Builds strong relationships with customers; stays aware of customer needs, concerns and satisfaction; responds promptly to customer questions and requests; effectively manages Supporting Change – Enthusiastically participates in new change initiatives and programs; focuses on reasons why changes will work and how they will be beneficial Supporting Organizational Goals – Actively supports organizational goals and values; demonstrates enthusiasm toward the company’s goals and mission; aligns actions around organizational goals Working with Diverse Populations – Shows respect for the beliefs and traditions of others; encourages and promotes practices that support cultural diversity; discourages behaviors or practices that may be perceived as unfair, biased, or critical toward people with certain backgrounds Leaders Competencies Acting as a Champion for Change – Challenges the status quo; encourages people to question existing methods, practices, and assumptions; supports people in their efforts to try new things Demonstrating Initiative – Takes action on his/her own without being prompted; handles problems independently; able to resolve issues without relying on extensive help from others; does more than is expected or asked Developing Talent – Invests time and resources into building the capabilities of team members; helps people define career goals and establish development plans to achieve them; gives people constructive, developmental feedback and advice Managing Performance – Clearly defines and communicates roles and responsibilities; holds people accountable for accomplishing objectives; recognizes and rewards people who achieve results and deliver on performance expectations; provides effective feedback on performance |