Director of Medical Management - Inpatient/Outpatient
Santa Clara, CA
Responsible for the work flows, procedures, and clinical tools used for integrated health medical management operations including utilization management, complex case management, disease management, and wellness activities. Leads the ongoing management and operations of these processes and will collaborate with the Chief Medical Officer as needed in functions that pertain to these activities.
- The Director leads all aspects of clinical operations procedure development and documentation, including developing and monitoring workflows, templates, checklists, policies, and procedures. They will be responsible for the success of the Utilization Management and Case Management departments. The Director assists 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.
- Responsible for the daily management of utilization management staff and the medical case management staff. In addition this position must successfully execute and supervise key initiatives of the Medical Case Management, specialty complex condition initiative programs, and state waiver programs to ensure compliance with contractual requirements. Understand, promote and audit the principles of UM & CM to facilitate the right care at the right time in the right setting. Identify trends or issues in the UM/CM process that require further evaluation for their quality or utilization implications. Communicate effectively and interact with the medical directors, hospitalists, provider offices, staff and health plans daily or as indicated regarding UM/CM and referral authorization issues.
- The Director consults in implementation and continuous improvement of clinical program operations. They organize and facilitate weekly UM & CM 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 turnaround times for all statuses are compliant 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. Verify that any new process is communicated to the UM/CM Staff and is followed via monthly audits of the staff’s production.
- BSN or MSW with CA current unrestricted state license as Registered Nurse or Social Worker.
- Case Management Certification (CCM) and/or Master’s degree in health care or business is preferred.
- 6+ years’ clinical experience in a high acuity setting.
- 6+ years’ experience in Case Management, Utilization Management, or other operations for a Managed Care Organization (Health Plan, IPA, HMO, TPA, etc).
- Demonstrated knowledge of Knox, Keene Act, Federal HMO Act, Nurse Practice Act, The Joint Commission, and all other local, state, and federal regulations.
- 5+ years previous management and supervisory experience, in roles of increasing responsibility, which included hiring and supervising nurses.
- 3+ years demonstrable experience in the development, revision, and implementation of utilization management policy and procedure
- Strong computer proficiency (MS Office and Healthcare IT Systems) and typing skills are necessary.
- Able to transform assignments from high-level objectives into independently established detailed goals.
- Excellent verbal and written communication skills, as well as exceptional critical thinking skills.
- Knowledge of utilization management, quality improvement, discharge planning, and cost management.
- Possess planning, organizing, conflict resolution, negotiating and interpersonal skills.