Supervisor, Outpatient Utilization Management

US-CA-Alameda
3 weeks ago
Job ID
2017-1699
# of Openings Remaining
1
Experience (Years)
4

Overview

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  . 

Responsibilities

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. 

 

ESSENTIAL FUNCTIONS OF THE JOB

· 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.

 

PHYSICAL REQUIREMENTS

· 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.

Qualifications

EDUCATION OR TRAINING EQUIVALENT TO:

 

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

      or

· 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 YEARS OF ADDITIONAL RELATED EXPERIENCE:

 

· 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.

 

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

 

· 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

Options

Sorry the Share function is not working properly at this moment. Please refresh the page and try again later.
Share on your newsfeed