RN Manager of Utilization Management

Location: Santa Barbara, CA
Date Posted: 08-31-2018
CareNational
RN Manager of Utilization Management - Managed Care
Santa Barbara, CA
 
$$$ Generous Relocation Package available to attract top-talent from around the Nation! $$$

Manager of Utilization Management Job Summary:  
  • RN Manager of Utilization Management promotes the quality and cost effectiveness of prior authorization and concurrent review functions. 
  • Responsible for management and oversight of daily managerial operations pertaining to utilization management; including but not limited to training, development of process and quality review programs that maximize quality while utilizing appropriate resources within the members’ benefit plans and established contracts
  • The Manager is responsible for being the first line resource for inpatient concurrent review and prior authorization staff.   
  • The Manager assists the Regional Director of Medical with daily management of concurrent and prior authorization review staff, auditing functions, and assuring that all staff provides a level of customer service that meets or exceeds the organization’s expectations. 
  • Understand, promote and audit the principles of Utilization Management to facilitate the right care at the right time in the right setting. 
  • Identify trends or issues in the UM process that requires further evaluation for their quality or utilization implications and bring these items to the attention of the Utilization Management Director. 
  • Communicate effectively and interact with the medical directors, hospitalists, provider offices, staff and health plans daily or as indicated regarding UM and referral authorization issues. 
  • Possess excellent case management skills including but not limited to, development and monitoring of care plans, post discharge calls, Vital Care referrals, hospital contracts, stop loss and DRG. 
  • Organize and facilitate weekly Utilization Management Meetings to disseminate new information. 
  • Verify that benefits are checked via monthly audits of the staff’s production.
  • Verify that the process in place for collecting data for deferred referrals is followed via monthly audits of the staff’s production.
  • Verify that the process in place for processing urgent/stat referrals is followed via monthly audits of the staff’s production.
  • Verify that the denial process in place is followed and compliant via monthly audits of the staff’s production.  

Manager of Utilization Management Background: 
  • Valid, unrestricted state Registered Nurse (R.N.) license.
  • Bachelor of Science in Nursing (B.S.N.) or related field required, or 2+ additional years of direct UM leadership experience.
  • Certification in Case Management (CCM) or Utilization Management (CPUM/CPUR/CPHM) is a plus.
  • Roughly 3-5 years of acute care clinical nursing experience; higher acuity settings (ICU, CCU, ER, med-surg) preferred.
  • At least 4-5 years Care Management / Utilization Review / Discharge Planning experience (mix of all preferred).
  • 2-4 years of progressive supervision or management experience within a managed care or hospital environment.
  • At least 2-3 years’ experience in a Managed Care Organization (Health Plan/HMO/MSO/TPA/IPA/etc); Medi-Cal preferred.
  • Strong working knowledge of Utilization Review processes in a Managed Care environment is required.
  • Experience with FACETS, CCMS, InterQual or other healthcare database.
  • Extensive knowledge of Medicare, Medicaid and similar state health programs, their regulatory guidelines, benefit management and coverage determination, reconsideration, and appeal processes.
  • Ability to analyze and integrate information and make sound decisions based upon established guidelines.
  • Resourcefulness as demonstrated by the effective application of professional knowledge to new situations.
  • Possess planning, organizing, conflict resolution, negotiating and interpersonal skills.
  • Experience in training, teaching, and coaching staffs to meet operational requirements and goals.
  • Basic computer proficiency (MS Office Excel, PowerPoint, and Access and Healthcare IT Systems) and typing skills.
  • Strong oral and written communication skills; ability to interact with all levels of internal and external contacts.
  • Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously

# CLINICAL
PRASHANT PATEL
STRATEGIC DIRECTOR
CareNational
prashant@carenational.com
480.646.3275 (CALL – TEXT – FAX)
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