RN Supervisor of Utilization Review - Managed Care
San Leandro, CA (East Bay, south of Oakland)
Supervisor of Utilization Review Job Summary:
Supervisor of Utilization Review Background:
- Oversees an integrated Care Access and Monitoring team responsible for prior authorizations, inpatient/outpatient medical necessity/utilization review, and/or other utilization management activities aimed at providing members with the right care at the right place at the right time.
- Functions as a hands-on supervisor, coordinating and monitoring clinical and non-clinical team activities to facilitate integrated, proactive utilization management, ensuring compliance with regulatory and accrediting standards.
- Manages and evaluates team members in the performance of various utilization management activities; provides coaching, counseling, employee development, and recognition; and assists with selection, orientation and mentoring of new staff.
- Performs and promotes interdepartmental integration and collaboration to enhance the continuity of care including Behavioral Health and Long Term Care for members.
- Ensures adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and other performance indicators.
- Collates and reports on Care Access and Monitoring statistics including plan utilization, staff productivity, cost effective utilization of services, management of targeted member population, and triage activities.
- Completes staff quality audit reviews. Evaluates services provided and outcomes achieved and recommends enhancements/improvements for programs and staff development to ensure consistent cost effectiveness and compliance with all state and federal regulations and guidelines.
- Maintains professional relationships with provider community and internal and external customers while identifying opportunities for improvement.
- Current, valid, and unrestricted state Registered Nurse (R.N.) license.
- Bachelor degree in Nursing or related field, and/or certification as CCM, CPUR/CPUM/CPHM, CPHQ or similar is preferred
- 2-3 years acute care clinical nursing experience is required.
- Requires around 3 years of recent experience in Utilization Review or Utilization Management at a health plan or other managed care organization (HMO/TPA/IPA/etc).
- 1-2 years experience as a RN in a lead, supervisory or management role is preferred.
- Knowledge of guidelines for Medicaid/Medicare and related state programs is required.
- Experience using Milliman or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
- Computer skills to include Microsoft Word, Excel, database use, and basic data entry.
- Must be willing and able to travel locally, if needed.