Requisition ID: 761780
Position: Full-Time
Total Rewards: Benefits/Incentive Information (https://jobs.luxottica.com/content/Benefits-and-Perks/?locale=en_US)
There's more to EyeMed than meets the eye. EyeMed is the fastest growing managed vision benefits company in the country with consistent double-digit membership growth! Through our commitment to innovation, we're reimagining the way employers and their employees think about vision care. We want them to see life to the fullest and experience more of what's best, not more of the same. And if what's best hasn't been done yet, it's our exceptional and passionate employees driving this change. But, our passion for vision isn't just about vision insurance benefits. Our employees are proud to support and participate in life-altering global and local missions through our partnership with OneSight, a leading not-for-profit organization with a 100% focus on eradicating the world's vision crisis.
Your family says a lot about who you are. EyeMed is a key member of the Luxottica family of companies, global leaders in the design, manufacture and distribution of fashion, luxury and sports eyewear. In North America, Luxottica is the home to global brands Ray-Ban, Oakley and many top fashion house brands. Our leading retail brands include LensCrafters, Sunglass Hut, Pearle Vision, and Target Optical.
If you're passionate about driving innovation and change and interested in a career in the optical and insurance industry, EyeMed wants to start the conversation and help provide you a growth-focused opportunity with America's fastest growing vision benefits company.
GENERAL FUNCTION
The Utilization Manager collaborates with healthcare providers and members to promote quality member outcomes, optimize member benefits, and promote effective use of resources. The Manager ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of outpatient services, focused on surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, and accurately interpreting benefits and managed care products. The Manager oversees system process and workflow for the UM team. The Manager works closely with the Medical Director to interpret appropriateness of care and accurate claims payment.
MAJOR DUTIES AND RESPONSIBILITIES
Oversee pre-certification, concurrent or retrospective reviews for appropriateness of treatment to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
Ensures member access to medically necessary, quality eye care in a cost-effective setting according to contract.
Collaborates with providers to assess members' needs for early identification of and proactive planning for treatment plans.
Partners with IT and Operations to develop system process and workflows, and to resolve any system issues.
Consults with peer clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the UM process.
Supervises and assists the UM Analysts
Summarizes cases for the peer clinical reviewers or medical director to review using appropriate protocols based on members' clinical and benefit information.
Prepares case files for external reviews or forwarding to health plans.
Maintains record and documents results of the clinical review and determination in the appropriate system.
Facilitates member care transition through the eye care continuum and refers cases to peer clinical reviewers as required and does not issue non-certifications.
Lead and facilitate cross-functionally the accreditation process by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
Represents the company during client facing meetings and establishes working relationship with clients
Maintains awareness of industry trends and developments related to utilization management and the measurement of vision care quality and cost efficiency.
BASIC QUALIFICATIONS
Bachelors Degree or equivalent work experience
5+ years of experience in a related field
2+ years acute care clinical experience
Strong oral and written communication skills, problem-solving skills, facilitation skills, and analytical skills
Supervisory or people leadership experience
Familiar with medical coding and billing
Proficient in Microsoft Office
Knowledge of and experience with Medicaid and Medicare regulations
Strong organization and multi-tasking skills
Demonstrated ability to meet deadlines with high sense of urgency
PREFERRED QUALIFICATIONS
2+ years Utilization Management experience in managed care, acute, or rehab setting
Knowledge of utilization review process and prior authorization process in a managed health care industry
Prior participation in URAC/NCQA accreditation activities
Experience in Project Management
Upon request and consistent with applicable laws, Luxottica will provide reasonable accommodations to individuals with disabilities who need assistance in the application and hiring process. To request a reasonable accommodation, please call the Luxottica Ethics Compliance Hotline at 1-888-887-3348 (be sure to provide your name and contact information so that we may follow up in a timely manner).
We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, gender, national origin, social origin, social condition, being perceived as a victim of domestic violence, sexual aggression or stalking, religion, age, disability, sexual orientation, gender identity or expression, citizenship, ancestry, veteran or military status, marital status, pregnancy (including unlawful discrimination on the basis of a legally protected pregnancy or maternity leave), genetic information or any other characteristics protected by law. Native Americans receive preference in accordance with Tribal Law.
