Overview

The Manager of Utilization Management (UM) will provide leadership and clinical oversight foroperational aspects of UM, including the responsibility for providing daily oversight, leadership,support and management of assigned staff. Collaborates with Supervisor(s) to oversee thedepartment activities and provides guidance to manage these functions to enhance costeffectiveness, ensure compliance with applicable state and federal regulations, and to fulfill allcontractual requirements.

Responsibilities

• Provides day-to-day direction to Supervisors and licensed clinical staff regarding utilization review, care coordination, discharge planning and other services across the continuum of care.
• Ensures compliance with regulatory/accreditation (NCQA, DHCS, CMS, DMHC, etc.) requirements related to UM by partnering with other departments and maintaining survey readiness; participating in audits upon request
• Identifies and incorporates evidence-based best practices (ex. Transitional Care Services, discharge planning, case management models, etc.) into department programs and activities to improve the quality of care and reduce costs.
• Monitors trends in daily inpatient census and mobilizes supports and/or tools to address length of stay (LOS) in acute care settings.
• Collaborates with the department trainer and other leaders to develop tools and/or training materials for clinical staff.
• Supports and/or leads interdisciplinary team rounds with other Partnership staff (ex: Medical Director, CC staff, etc.) to address best practices of care across the continuum, discharge planning, out-of-area placements, and/or guidance for complex discharges for Partnership members.
• Monitors work assignments to ensure appropriate staff assignment in accordance with job descriptions, practice level, and business needs.
• Works closely with Health Services leadership to develop meaningful performance measures to determine the quality, effectiveness, and efficiency of department operations in achieving desired outcomes.
• Provides administrative, technical, and clinical management of assigned staff including the responsibility for hiring, timecard management, performance evaluation, education, staff development, work allocation and/or problem resolution.
• Works with other departments to resolve claims, grievance, CC, PR, QI, RAC and member issues as necessary.
• Develops structures, relationships, and processes to promote active partnerships with providers, community stakeholders, and/or other healthcare professionals to meet and support key organizational initiatives (ex: Hospitals, DME vendors, MOU requirements, CalAIM, etc.)
• Leads meetings and/or presentations related to UM activities, operations and/or programs.
• Optimizes use of technology to enhance work productivity, quality, cost and/or outcomes
• Collaborates with contracted Partnership vendors in the delivery of medically necessary services and/or support tools.
• Develops and participates in annual organizational and departmental goals that support Partnership’s strategic plan, goals and mission.
• Reviews and participates in operationalizing newly released All Plan Letters (APL)
• Serves as a role model and resource to colleagues, staff, members, and others across assigned regional offices.
• Reviews and routes Letters of Agreement (LOA) as appropriate
• Assists in the development and implementation of departmental policies and procedures.
• Surfaces issues or suggestions to the appropriate team members or leaders.
• Other duties as assigned.

Qualifications

Education and Experience

Bachelors of Science in Nursing preferred; minimum five (5) yearsacute care experience, two (2) years managed care experience; orequivalent combination of education and experience. Minimum one (1)year prior experience in a leadership or management role.

Special Skills, Licenses and Certifications

Current California Registered Nurse License. Certifications in chosenfield such as advance practice nursing or case management highlydesired. Valid California Driver's License and proof of currentautomobile insurance compliant with Partnership’s policies arerequired to operate a vehicle and travel for company business.

Performance Based Competencies

Knowledge of DHCS, Medi-Cal, DMHC, and/or NCQA regulations.Strong working knowledge of nursing standards in both inpatient andoutpatient settings. Thorough knowledge of Utilization Reviewprocesses and principles (concurrent, retrospective, discharge planning,care coordination, etc.). Familiarity of business practices and protocolsaccessing data sets and information using automated systems. Ability to work within an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities anddeadlines. Strong organizational skills required. Computer literacy andproficiency. Excellent written and verbal communication skills inEnglish. Demonstrated experience and ability to build effectiveworking relationships and to represent the department effectively inorder to accomplish goals. Ability to manage multiple concurrentprojects and maintain a work pace appropriate to the workload. Abilityto assist individuals in recognizing and solving problems. Ability tosupervise, train, motivate, provide guidance to staff 

Work Environment And Physical Demands

Ability to use a computer keyboard. Ability to prioritize workload andinitiate action to acquire needed information from professionals byphone. Ability to function effectively with frequent interruptions anddirection from multiple team members. More than 50% of work time isspent in front of a computer monitor. Must be able to lift, move, or carry objects of varying size, weighing up to 10 lbs. Some travel required (up to 25%) including occasional overnight.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$ 120,686.00 - $ 156,735.06

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.