Supervisor, Outpatient Utilization Management

3 months ago
Job ID
# of Openings Remaining
Experience (Years)


The first level Supervisor, Outpatient Utilization Management (UM) Operations, under the direction and supervision of the Manager, Clinical Review & Utilization Management Operations, is responsible for monitoring and supervising the administrative staff performing prior authorization and basic care coordination activities for inpatient, outpatient, retro review, and case/disease management  . 


Principal responsibilities include:


· Develop and monitor daily production goals. 

· Create and refine departmental documentation, including standards and procedures, guidelines, workflows, program evaluation, and other relevant records. Responsible for timely revisions, maintenance, and storage of such documentation. 

· Prepare and analyze operational and production reports. 

· Respond to and interpret Alliance protocols and guidelines for authorizations.

· Assure compliance with all payer (including hospital, DME) contracts and delegated network Division of Financial Responsibility (DOFRs), as related to prior authorization rules

· Assure departmental compliance with Medi-Cal, CMS, NCQA, as well as all county, state, and federal regulations and mandates. 

· Interface with and advise management on opportunities to improve efficiency of the prior authorization process.

· Serve as Inpatient & Outpatient UM “subject matter expert” to Alliance. Conduct necessary research and subsequent training on relevant and current issues in the industry.

· Actively participate in intradepartmental management team meetings. Frequently strategize with others in Quality, UM, Pharmacy, G & A, and Health Education ensure overall optimal performance of the Health Plan Services department.

· Act as the liaison between other internal departments including, but not limited to Provider Relations, Member Services, Claims, Case and Disease Management, I.T., Compliance, etc.

· Serve as the liaison between Alliance and outside organizations including, but not limited to hospitals, vendors, and delegated medical groups to help resolve situations with authorizations, eligibility, and claims.

· Actively participate in recruitment, hiring, and training of staff. 

· Supervise daily activities of staff including distribution of workload. 



· Hire, supervise, and train staff.

· Perform writing, administration, analysis, and report preparation.

· Problem identification and resolution.

· Participate in audit activities.

· Excellent verbal and written communication skills.

· Lead and participate in internal and external committees and meetings.

· Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.



· Constant and close visual work at desk or computer.

· Constant sitting and working at desk.

· Constant data entry using keyboard and/or mouse.

· Constant use of telephone headset.

· Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.

· Frequent lifting of folders and objects weighing between 0 and 30 lbs.

· Frequent walking and standing.

· Occasional driving of automobiles.




· Bachelor’s degree from an accredited college with a major in human services, psychology, or other relevant focus,


· AS/AA degree or two years of college required with a minimum of one year experience making healthcare-related assessments and referrals, and/or experience in working with diverse clients with multiple barriers (including physical and behavioral health).




· Minimum four years customer service and office experience in the health care field (preferably in a health plan setting) and a working knowledge of medical and insurance terminology required.  Other medically related fields may be considered. (e.g., physician office, home health department, physical therapy office).

· Minimum three years supervisory experience in a health care or managed care environment or 2-3 years on the job Alliance experience in Utilization Management with executive/CEO level authorization is required.




· Proficient in medical terminology and CPT, ICD9-CM, ICD10-CM, NDC codes.

· Excellent verbal communication skills and effective written communications skills required.

· Ability to write and implement policies and procedures. 

· Ability to motivate and train staff.

· Well organized and detail oriented.

· Ability to handle multiple projects and balance competing priorities and short deadlines.

· Demonstrated skills in problem resolution, independent thinker, and logical. 

· Bilingual in Vietnamese, Cantonese, or Spanish, a plus.

Skilled proficiency in the use of computer software including Windows and current Microsoft Office suite


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