Responsible for the implementation and oversight of daily operations associated with all of the functions, programs, processes, and services within the utilization management department. Shall establish a staffing structure necessary to ensure that the functional responsibilities of UM services are conducted in a timely and efficient manner, coordinated in collaboration with the other functional departments, and performed in accordance with established policies and procedures.
COMPLIANCE WITH REGULATIONS
Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D, DHCS and DHMC.
Provides administrative oversight and monitors utilization of outpatient referrals by developing and implementing systems for the management of all outpatient utilization management programs; developing systems to track turn around times to ensure compliance with contract requirements; ensure all staff is fully trained in all aspects of effective outpatient utilization management processes to ensure effective processing of outpatient referrals.
Maintains staff job results by coaching, counseling, and disciplining employees; planning, monitoring, appraising and following up on job results.
Maintains efficient daily operations of concurrent review by initiating, coordinating, and enforcing program, operational, and personnel policies and procedures; developing, revising, and implementing work-flow and productivity parameters; trouble-shooting with practitioners, providers, facilities, and CHG staff when needed; providing hands-on case management and utilization review.
Maintains systems that identify cases/patterns of over and underutilization by analyzing historical trends, reviewing established guidelines and protocols, and pursing corrective actions based on findings; monitors/reports appropriate utilization of resources consistent with community practices.
Provides administrative oversight and monitors utilization of telephone advice nurse program by analyzing statistics based on standard utilization reports; troubleshooting and resolving access issues; regularly meeting with contractor to ensure smooth service delivery of telephone advice nurse services to all plan members.
Provides oversight and overall coordination of the Language Assistance Program to ensure compliance with regulatory requirements.
Develops and implements network providers training sessions based on membership need; collaborating with plan staff to incorporate training opportunities related to community and preventive health services at initial provider orientation and other forums as needed.
Develops and implements formal Memorandum of Agreement/Understanding (MOAs/MOUs) by developing and operationalizing internal policies and procedures to comply with regulatory requirements; providing liaison with local health programs to coordinate services for plan members; facilitating communication between local/state health departments and departments within the health plan to problem solve as needed; representing health plan in standing meetings as required in the MOAs.
Provides overall administration and coordination of Utilization Management Committee by coordinating standing meetings; expanding membership to ensure compliance with regulatory requirements.
Supports the team effort by assisting all CHG departments with program implementation and overall operations; attending meetings as required and participating on committees as directed; and performing other related duties as assigned or requested.
Enhances professional growth and development by participating in educational workshops, seminars, and related training; reviewing current literature.
Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.
Reviews and updates UM policies and procedures on an annual basis.
Coordinates and prepares for all regulatory audits with the goal of having zero negative findings.
Coordinates and prepares needed UM materials during the NCQA accreditation.
Conducts required UM surveys and conducts annual UM program evaluation.
Oversees the Health Homes program.
Other Duties as assigned.
Active and unencumbered California RN license
Master's Degree Preferred
6-7 years managed care experience
4-5 years of direct supervision experience
Knowledge of M&R and/or other UM criteria
Full working knowledge of Microsoft Office software
Knowledge of applicable state and federal laws and NCQA and working knowledge of Medicaid, CCS required
Experience in interpreting Utilization and benefit data
Strong communication skills; analytical; ability to organize work effectively, determine priorities; works well independently and as a team player
Knowledge of case management methods
Knowledge of managed care principles, CPT, ICD-9, HCPCS coding, experience with inpatient and outpatient medical review guidelines (MCG).
Conceptual strength is essential as are analytical, verbal and written communication skills; good public relations
California Drivers License and proof of auto insurance.