The Manager, Outpatient Utilization Management (UM) works under the direct supervision of the Director, Clinical Services. This position oversees the outpatient utilization management (UM) team focusing on utilization management and care coordination to assure integration of all Health Plan Services department operations. The Manager is responsible for policy, program development and implementation to assure quality care and cost effective services to members. This position is responsible for management and supervision of the outpatient UM team and maintaining strong working internal and external relationships.
Principal responsibilities include:
· Collaborate in implementing and monitoring departmental strategic plans for utilization management and care coordination.
· Develop and oversee systems for outpatient authorizations, productivity metrics and meaningful management reports of both activities and outcomes. This will include analysis and reporting on utilization, health outcomes, care coordination and expenses with comparison to state and national standards and benchmarks.
· Conduct ongoing analysis that results in department changes to boost efficiency and effectiveness and align work processes with department goals and objectives.
· Assure staff and department compliance with all regulatory, contractual and accreditation requirements and provide documentation for audits and reviews, including CMS, DHCS, DMHC, and NCQA.
· Assist the organization with preparation and maintenance of NCQA accreditation.
· Review and update policies and procedures and assure consistency with regulations, contracts, Provider Manual, Evidence of Coverage and other plan documentation. This may be performed in conjunction with other managers and directors.
· Assist with preparation of the annual UM evaluation report, and other reports and presentations for internal and external departments and organizations as assigned.
· Work in a collaborative manner across the organization to achieve department and overall organizational goals.
· Work with the Director, Clinical Services and Medical Director(s) to ensure appropriate clinical guidelines are developed and practiced
· Review outpatient and elective inpatient admission authorization requests.
· Actively participate in recruitment, selection, and training of staff. Develop and communicate staff performance plans. Conduct annual performance appraisals. Implement corrective measures and discipline as necessary.
· Support and coordinate the day-to-day department activities by coaching and assisting the clinical and non-clinical staff.
· Lead any technological implementations for the unit.
· Provide training, development, and continuing education to staff.
· Maintain professional and technical knowledge.
· Perform other duties and special projects as assigned.
ESSENTIAL FUNCTIONS OF THE JOB
· Applying clinical guidelines to the review of authorizations
· Developing and analyzing systems and processes to achieve quality and efficiency measures.
· Developing quantitative and qualitative management reports and analyzes data.
· Communicating effectively and efficiently internally and externally.
· Supervising and training of staff to include but not limited to team building, evaluations, corrective actions, and progressive discipline procedures.
· Writing, reporting, administration, and analysis.
· Developing verbal presentations.
· Leading and participating in internal and external committees and meetings.
· Complying 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.
· Extensive typing required.
· Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
· Occasional travel between offices for meetings.
· Frequent lifting of folders and other objects weighing between 0 and 30 lbs.
· Frequent walking and standing.
· Occasional driving of automobiles.
EDUCATION OR TRAINING EQUIVALENT TO:
· Registered Nurse license, active and unrestricted licensed in the State of California, Board certified required.
· Master’s Degree (M.S.N, N.P.H., or M.H.A.) preferred.
· Have a cleared TB test prior to or within seven days of hire.
· Current CPR and first aid card prior to or within six months of hire is preferred.
· Certified Professional Utilization Review/Utilization Management preferred.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
· Minimum five years healthcare related experience
· Minimum five years working within the health care/managed care environment.
· Minimum three years managerial /supervisory experience in health care.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
· Knowledge of Medi-Cal and/or Department of Health Services and/or Medicare regulations and standards preferred.
· Strong utilization management, quality management, and care coordination background and skills.
· Ability to motivate, train, and supervise.
· Ability to make thoughtful decisions and exercise sound judgment.
· Ability to analyze and synthesize UM and care coordination information.
· Experience with planning, implementing, and evaluating clinical and disease prevention programs.
· Background in population-based community health assessment and interventions.
· Ability to work effectively in a multidisciplinary approach in management.
· Ability to communicate effectively, both verbally and in writing.
· Possess flexibility and creativity.
· Familiarity with programmatic and clinical research strategies in managed care settings preferred.
· Experience in use of various computer system software as well as Windows and current Microsoft Office suite.