Manager, Utilization Management
Location: Orange, California US
Job Number: 1677
Position Title: UM Manager
The Manager, Utilization Management, under the direction of the Director of Utilization Management, is responsible for: 1) the ongoing management of the UM Department 2) the ongoing management of the Prior Authorization Program, and Inpatient Case Management Program, 3) the direct supervision of licensed and coordinator staff performing UM and CM duties, 4) promoting quality patient care outcomes while supporting appropriate resource management along the continuum of care.
Essential Duties and Responsibilities
Essential duties and responsibilities include, but are not limited to:
- Training new UM / CM staff and coaching current staff (Includes both licensed and coordinator staff)
- Ensuring that UM clinical staff members are conducting telephonic concurrent review and performing Pre-Service Review on submitted requests within CMS and CCHP Turn Around Timeframes.
- Ensuring that the Clinical staff is utilizing approved Clinical Criteria.
- Ensuring that all staff is using CMS approved letter templates when communicating UM decisions / actions to members.
- Ensuring that all staff is using CMS / CCHP approved language in Member communication.
- Ensuring that all staff are managing and transferring members according to the Continuity of Care requirements.
- Ensuring that all staff complies with CMS and CCHP interdepartmental processes when participating in the Medical Claims Review processes.
- Ensuring that CM staff members are conducting telephonic review of members to ensure medical necessity and appropriate discharge planning needs are met
- Ensuring that all staff are documenting according to internal processes as outlined in Department policies, protocols and standard operating procedures.
- Collecting, evaluating and reporting data and activities as applicable within the UM / CM programs (i.e.: Monthly Reports, Policies and Procedures, and Medical Services Committee Reports (MSC))
- Interfacing with primary care physicians, specialty care physicians, mental health professionals, home health professionals and other health care professionals regarding patient care.
- Maintaining confidentiality of information between and among health care professionals.
- Counseling, planning and training, while managing various staff.
- Performing daily UM Reviews and Case Management when required, and handling escalated cases.
- Implementing CCHP- internal and CMS-specific programs (i.e., Medical Claims Review, CCIP )
- Developing, reviewing and revising as necessary, policies, procedures, protocols and processes related to UM, CCIP, and CM,
- Other duties as requested or assigned.
This individual supervises the Nurse Case Managers, Coordinators, Clerical staff, and others, as assigned.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Education and/or Experience: RN preferred, LVN required with clinical experience; two to three years related experience in a managed care setting; one year recent and related supervisory experience
- Certificates, Licenses, Registrations: Current, Active and Unrestricted California Registered Nursing or LVN license; CCM, or ABQAURP certification preferred
- Other Qualifications:
- Knowledge of Medicare Managed Care Plans
- Computer Skills: Word, Excel, Microsoft Outlook
- Experience with the application of clinical criteria (i.e., Apollo, CMS National and Local Coverage Determinations, etc.)
Skills and Abilities
- Language Skills: Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors.
- Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly.
- Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
- Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
- Report Analysis Skills: Comprehend and analyze statistical reports.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.
- The employee is frequently required to reach with hands and arms.
- The employee is occasionally required to climb or balance and stoop, or kneel.
- The employee must occasionally lift and/or move up to 20 pounds.
- Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- The noise level in the work environment is usually moderate.
Location City: Orange
Location State: California
Community / Marketing Title: Manager, Utilization Management
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