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.
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.
· 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.
EDUCATION OR TRAINING EQUIVALENT TO:
· 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 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