As a Utilization Management Supervisor, you will play a pivotal role in managing and supporting a team of remote employees. Your responsibilities will include overseeing Prior Authorizations, and/or Retrospective Review that the Clinical Review team completes to ensure appropriate care to members. You will supervise day-to-day activities of Utilization Management team including assisting with questions, reviewing client-based letters, conducting monthly client reporting, and analyzing trends of UM reports. You will perform monthly audits on your team to ensure compliance and quality and conduct one-on-one coaching sessions with your Lead to foster their professional growth. Also, you will help with upkeeping internal department documents and review questions and concerns from other departments within the company. When necessary, you will perform testing and train your staff members. You will process prior authorization requests when necessary to meet turnaround times. Your leadership and organizational skills will be essential in maintaining team efficiency and achieving departmental goals.  

Competencies:   

• Self-Motivation & Organization: Must be self-motivated and highly organized with the ability to work autonomously without direct supervision. 

• Flexible Hours: Work hours will be determined by your manager and may vary based on location, department needs, and workflow. Additional hours outside of normal shifts may be required. 

• Deadline Adherence: Expected to meet established deadlines and deliver high-quality work consistently.  

• Virtual Collaboration: Use virtual platforms like Teams and Microsoft Outlook for collaboration. Participate and conduct monthly/quarterly check-ins and bi-weekly department touch bases for market updates and team alignment.  

• Confidentiality: Maintain strict confidentiality of information related to Avēsis and its customers, following our information security policies. This obligation continues even after employment ends, including secure handling of data and access management.  

 Functional: 

• Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards. 

• Collaborates with UM team to resolve complex processing issues. 

• Maintains knowledge of regulations, accreditation standards, and industry best practices related to Utilization Management. 

• Works with UM team and senior management to identify opportunities for process and quality improvements within UM Dept. 

• Educates and provides resources for the UM team on key initiatives and to facilitate on-going communication between UM team, members, and providers. 

• Monitors prior authorization, and/or retrospective clinical review team and ensures compliance with applicable guidelines, policies, and procedures. 

• Works with Senior Management to develop, monitor, and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services. 

• Evaluates UM team performance and provides feedback regarding performance, goals, and career milestones.  

• Coordinates staff scheduling based on workflow needs, and maintains tracking and logging of staff attendance, production metrics, and timecards. 

• Provides coaching and guidance to UM team to ensure adherence to quality and performance standards by utilizing metrics and management reports to monitor. 

• Assists with onboarding, hiring, and training UM team members. 

• Leads and champions change within scope of responsibility. 

• Performs other duties as assigned. 

• Demonstrate knowledge and understanding of client contracts and performance requirements, authorization processing workflow, approval/denial, and letter generation processes.  

• Manage inventory and make recommendations for improving outcomes.  

• Provides ongoing communications with the staff to ensure their operational skills and capabilities are maintained. 

 Core: 

• Shows a high level of dedication to a commitment to excellence, working hard to deliver on commitments to others and ensure quality of care. 

• Holds self and others accountable to meet commitments. 

• Makes good and timely decisions that keep the organization moving forward.  

• Executes a solution-oriented approach to conflict and challenges. Makes sense of complex and high quantity information to effectively solve problems. 

• Ability to convey information and engage an audience in a professional setting.  

• Work with other internal departments as necessary to implement strategies to proactively manage utilization volume within each market to assure client turnaround times are met.  

• Provide recommendations on department policies, objectives, and initiatives. Evaluate and suggest changes as necessary to optimize processes and efficiencies. Works in partnership with Avēsis personnel to improve system efficiency and collaborate on complex barriers that arise.   

• Ability to operate in a fast-paced environment under tight deadlines.  

• Ensures that the right systems, processes, and measurements are in place to assist with accurate clinical determinations.  

Behavioral:  

• Collegiality: building strong relationships on company-wide, approachable, and helpful, ability to mentor and support team growth.  

• Initiative: readiness to lead or take action to achieve goals.  

• Communicative: ability to relay issues, concepts, and ideas to others easily orally and in writing.  

• Member-focused: going above and beyond to make our members feel seen, valued, and appreciated. 

• Detail-oriented and thorough: managing and completing details of assignments without too much oversight. 

• Flexible and responsive: managing new demands, changes, and situations. 

• Critical Thinking: effectively troubleshoot complex issues, problem solve and multi-task. 

• Integrity & responsibility: acting with a clear sense of ownership for actions, decisions and to keep information confidential when required. 

• Collaborative: ability to represent your own interests while being fair to those representing other or competing ideas in search of a workable solution for all parties. 

Minimum Qualifications:  

• High School Diploma or GED is required.

• Dental Assistant certificate or 2 years of chair side assisting 

• Experience in a leadership or management role required 

• Experience and knowledge in intermediate computer skills 

• Exhibit strong skills for reading, writing, and communicating at a professional level 

• Proficiency in managing multiple tasks and prioritizing work  

• Ability to think analytically and make independent decisions 

• Ability to handle multiple and changing priorities 

• Capable of maintaining positive working relationships 

• Effective time management and organizational skills 

• Ability to work overtime as needed 

• Internet & Workspace: A reliable internet connection (25 MBPS upload/50 MBPS download speed) and an appropriate workspace are essential for success in this remote role. 

Preferred Qualifications:  

• Management/supervisory experience, 4 or more years. 

• 5 years clinical experience in the dental industry is a plus. 

• Knowledge of Medicare, Medicaid, and Commercial insurance. 

• Clinical experience within the dental and/or optical field preferred. 

• HCPCS, CPT, CDT, ICD 10 coding experience preferred. 

• Requires research and analytic skills or an ability to oversee, understand, and articulate the results of the research and analysis to perform many of the responsibilities outlined above. 

• Knowledge and understanding of regulatory language. 

• Excellent oral and written communications skills. 

• Experience managing cross functional projects. 

• Knowledge of managed care health plans operations and HIPAA (Health Insurance Portability and Accountability) guidelines. 

• Strong skills using Microsoft applications and other windows-based tools. 

FLSA Status: Salary/Exempt

National Salary Range: $55,790 - $87,230

How To Stay Safe:

Avesis is aware of fraudulent activity by individuals falsely representing themselves as Avesis recruiters. In some instances, these individuals may even contact applicants with a job offer letter, ask applicants to make purchases (i.e., a laptop or gift cards) from a designated vendor, have applicants fill out W-2 forms, or ask that applicants ship or send packages of goods to the company.

Avesis would never make such requests to applicants at any time throughout our job application process. We also would never ask applicants for personal information, such as passport numbers, bank account numbers, or social security numbers, during our process. Our recruitment process takes place by phone and via trusted business communication platform (i.e., Zoom, Webex, Microsoft Teams, etc.). Any emails from Avesis recruiters will come from a verified email address ending in @Avesis.com.

We urge all applicants to exercise caution. If something feels off about your interactions, we encourage you to suspend or cease communications. If you are unsure of the legitimacy of a communication you have received, please reach out to ITsupport@Avesis.com.

To learn more about protecting yourself from fraudulent activity, please refer to this article link (https://consumer.ftc.gov/articles/how-avoid-scam). If you believe you were a victim of fraudulent activity, please contact your local authorities or file a complaint (Link: https://reportfraud.ftc.gov/#/) with the Federal Trade Commission. Avesis is not responsible for any claims, losses, damages, or expenses resulting from unaffiliated individuals of the company or their fraudulent activity.