Under the direction of the Manager, Utilization Management (UM) this position is responsible for overseeing and managing the day-to-day operations of the Utilization Management Department, health plan delegated activities, and medical management initiatives. This position works closely with the Manager, Director, Medical Director and VP to evaluate and monitor medical appropriateness determinations and care coordination activities. This position is responsible for developing and implementing strategic plans which will have a direct impact on cost containment and improved patient outcomes.
Responsibilities1. Oversees referral/authorizations, denial processes, and correspondence with member and provider (ie. Denial letters, NOMNC, APTC letters, etc.)Ensures compliance with regulatory requirements and application of clinical decision support criteria for utilization activities deemed by Federal, State and other regulatory and accreditation agencies.Perform trouble-shooting when difficult situations arise and takes independent action to resolve.Oversees activities of utilization review as applicable to delegated entities.Completes desktop procedures and workflows and educates referral specialist accordingly.Monitors Utilization activities to ensure compliance with policies and procedures.Monitors and analyzes the productivity and quality of utilization management operations, while providing ongoing feedback and education for the staff.Performs audits of utilization management based on Health Plan Compliance needsCoordinates with the Compliance Department for Health Plan deliverables: delegation oversight audit requests, focus audit requests, and/or corrective action plansWorks collaboratively with the entire organization to be in a state of continual readiness for Delegation Oversight Audits performed by health plans for various functions Uses and/or oversees the use of data analysis and process improvement tools to monitor and improve performance.All other duties as assigned
QualificationsCalifornia LVN or RN with active, unrestricted license.Associate of Arts degree or equivalent work experience preferred coupled with a minimum of one year experience in a managed care environmentPrevious leadership experience preferredKnowledge of State and Federal regulations required.