Director, Utilization Management (RN/BSN)

Location: Irvine, CA
Date Posted: 07-12-2017
Our client delivers comprehensive care to Medicare, Medicaid, and complex-needs patients. For over a decade, we have provided extraordinary outcomes for thousands of people in these underserved groups. Thier name reflects our unique approach to healthcare. It’s about how we work in concert with patients, providers, and health plans. It’s about the harmony of a patient’s care, health, and dignity.

Job Summary
Reporting to the Senior Medical Director, Utilization Management, this position manages the daily operations of UM staff for our organization. This position will ensure that all processes, programs, and operations of utilization management are fully implemented. Programs include Utilization Management, Government requirements, and Audits. The position will work closely with the Medical Director to assure a sound Utilization Management Program.  In addition, this position is responsible for recruitment, hiring, training, development, and retention of staff. 
 
Responsibilities:
  • Implements Utilization Programs and policies and procedures to ensure that all functions meet internal, Health Plan, and Regulatory requirements.  
  • Implements, monitors and ensures Referrals meet provider and patient needs while maintaining and or improving utilization metrics.  
  • Ensures staff competency utilizing inter-rater reliability tools and evidence-based criteria for utilization review.  
  • Ensures that patients receive appropriate authorization and access to care, including timely information regarding authorizations.  
  • Collaborates with the Medical Director to identify opportunities for process improvement in utilization management that are consistent with the organization’s vision and strategic long-term goals.
  • Communicates with the staff both verbally and in writing to convey health plan, contract or operations information to ensure all staff members have a consistent and appropriate knowledge base to perform their duties.  
  • Promotes staff growth and development by identifying educational opportunities to increase efficiency and maintain compliance with industry standards.  
  • Participates in the collection, analysis, and reporting of data relevant to utilization management.  
  • Responsible for recruitment and selection of staff. Responsible for orientation of new staff, on-going training, mentoring, and performance reviews.
  • Conducts staff meetings, assuring policy and procedures are adhered to and when necessary, modified to address changing strategic objectives. 
Qualifications:
Minimum Position Qualifications:
  • Education: Requires either a Bachelor’s degree or a high school diploma or GED with equivalent years of related work experience in utilization/care management may be substituted. 
  • Experience: Requires five (5) years’ utilization management experience.  Three (3) years management experience in a progressive leadership role required. 
  • License / Certification: RN/BSN
  • Computer Skills: Basic computer skills in a Windows operating environment including Microsoft Word, Excel, and an e-mail system. 
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Knowledge / Skills / Abilities:‚Äč
 
  • Must be a dynamic leader, able to navigate a complex environment, with excellent verbal and written communication skills, as well as strong operations experience.  Ability to manage people through change.  Demonstrates flexibility through change.  Ability to lead and form a collaborative team.  Knowledge of NCQA and other regulatory agency requirements pertaining to the delivery of health care in the managed care setting.  Effective influencing, negotiation, relationship-building, and communication skills are essential.  Ability to work effectively under pressure due to changing priorities.  Effective employee management skills.  Possess strong leadership, critical-thinking, and motivational skills/abilities.  Knowledge of ambulatory healthcare delivery and management.   Excellent problem-solving and organizational skills.  Ability to work effectively and establish and promote positive relationships. 
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