The Supervisor, Utilization Management (Must have California LVN / RN License), under the direction of the Manager of UM, is responsible for ongoing management of the UM Department, the oversite of inpatient UM processes. Directly supervise licensed staff performing UM duties. Accountable for promoting quality patient care outcomes while supporting appropriate resource management along the continuum of care and responsible for auditing and completing reports to meet CMS compliance requirements.
Schedule: Must be willing to work Pacific Time hours.
GENERAL DUTIES / RESPONSIBILITIES
- Ensure UM clinical staff members are conducting telephonic concurrent review and performing Pre-Service Review on submitted requests within CMS and Alignment Healthcare turnaround timeframes as well as meeting department goals
- Ensure staff is utilizing Alignment Healthcare (AHC) approved clinical criteria.
- Ensure staff are following concurrent review and / or preservice workflow.
- Ensure staff are putting the member first while managing benefits appropriately
- Ensure staff are managing and transferring members according to the Continuity of Care requirements.
- Ensure that all assigned staff complies with CMS and AHC interdepartmental processes when participating in the Medical Claims Review processes.
- Ensure staff are conducting telephonic interviews of members to identify risk factors and the need for ambulatory CM and outpatient resources.
- Ensure that staff are initiating, developing, planning, implementing, and documenting care plans designed to promote the delivery of quality care and service to members in a timely manner.
- Ensure staff are considering the individual member's unique needs in the process of treatment planning within the CM programs
- Ensure staff are maintaining records according to the use of the current UM platform
- Ensure staff are using sound clinical judgment to make all final determinations
- Monitor staff are documenting according to internal processes as outlined in Department policies, protocols and standard operating procedures.
- Collect, evaluate, and report data and activities as applicable within the UM program. (i.e.: Monthly Reports, NOMNC, OMT, Medical Services Committee Reports (MSC))
- Interface with primary care physicians, specialty care physicians, mental health professionals, home health professionals and other health care professionals regarding patient care.
- Maintain confidentiality of information between and among health care professionals.
- Perform daily UM Reviews and Case Management when required and handling escalated cases.
- Implement Alignment internal and CMS-specific programs (i.e., Medical Claims Review)
- Develop, review and revise as necessary, policies, procedures, protocols and processes related to Inpatient and Preservice UM
- Other duties as requested or assigned
SUPERVISORY RESPONSIBILITIES
Oversee assigned staff. Responsibilities include recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees.
JOB REQUIREMENTS
Experience
Required
- Minimum (1) year recent and related supervisor experience
- Minimum (2) years related experience in a managed care setting, which includes inpatient and preservice utilization management
Education
Required
- Successful completion of an accredited Registered Nursing Program or Vocational Nursing program.
Specialized Skills
Required
- Knowledge of Medicare Managed Care Plans
- Computer Skills: Word, Excel, Microsoft Outlook
- Experience with the application of clinical criteria (i.e., MCG, InterQual, Apollo, CMS National and Local Coverage Determinations, etc.)
Licensure
Required
- Must have and maintain an active, valid, and unrestricted RN license in California (Non-Compact)
- Immediately upon hire, must be willing to obtain LVN and / or RN licensure in Nevada, (Non-compact), Arizona (Compact), North Carolina (Compact), and Texas (Compact) which will be reimbursed by company.
Preferred
- CCM or ABQAURP certification.
Essential Physical Functions
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
Pay Range: $85,696.00 - $128,543.00