MANAGER, UTILIZATION MANAGEMENT (Required: CA Clinical License, RN, LCSW, MFT, PHD, PsyD)

  • Beacon Health Options
  • Cypress, CA, USA
  • Jan 03, 2018
Medical

Job Description



Location
CA: Cypress

Job Family
Clinical, Licensed

Job Brief
UM Manager also monitors UM performance, and assists with UM activities as needed. UM Manager will be participating in health plan and regulatory agency audits. S/He is responsible for reviewing UM data and using data to improve productivity.

Exempt

ABOUT THE POSITION

We are currently seeking a dynamic Manager, Utilization Management to join our team at our office in Cypress, CA. The Manager, Utilization Management is responsible for the direct supervision of the Utilization Review Supervisors and UM Clinicians. S/he concentrates on areas of workflow development and ensuring consistency and accuracy of UM processes, reviewing and updating UM policies and procedures, team productivity and process improvement. UM Manager also monitors UM performance, and assists with UM activities as needed. UM Manager will be participating in health plan and regulatory agency audits. S/He is responsible for reviewing UM data and using data to improve productivity and efficiencies within the department.

Position Responsibilities:
  1. Responsible for supervision of Utilization Management Supervisors, Clinicians, and activities
  2. Complete quarterly chart audit of Utilization Management Staff
  3. Complete annual reviews of UM staff
  4. Monitor caseloads/workload and performance
  5. Assignment of after hour cases to UM staff for follow-up
  6. Responsible for staff schedule based on staffing needs of the department
  7. Assist with reviewing and updating UM policies and procedure
  8. Update and educate staff of any changes to policies and procedure
  9. Responsible for scheduling mandatory training for UM staff (Affirmative, Level of Care, Referral and Triage, Documentation, Legal, Advance Directive)
  10. Maintain a thorough knowledge of URAC/NCQA standards and regulatory requirements
  11. Assist/monitor consistency amongst UM staff in application of Level of Care Criteria
  12. Assist and monitor referral and triage process and review all emergent cases with Director of UM and CHIPA Physician Advisor
  13. Responsible for monitoring UM phone queue performance
  14. Responsible for reviewing cases for timeliness of UM decision and notification
  15. Responsible for coordinating clinical appeals with health plans
  16. Responsible for reviewing and coordinating with health plans on all clinical denial and notifications
  17. Provide weekly updates to Director of Utilization Management
  18. Maintain a thorough knowledge of covered benefits for populations served
  19. Participate in provider and plan meetings as assigned
  20. Facilitate monthly staff meetings to ensure that all staffs are provided with updated information on policies& procedures, level of care criteria, and any changes in the work plan.
  21. Facilitate weekly case conferences with CHIPA Medical Director and with Health Plan Medical Directors.
  22. Responsible for management/monitoring of Medical Director and Physician Advisors weekly schedule and availability
  23. Hiring and termination of department staff; enforcement of disciplinary procedures
  24. Training new UM staff/new hires regarding policy and procedures and level of care criteria
  25. Develop relationship and acting as back-up liaison with payers, providers and facilities regarding UM policies and procedures.
  26. Attend and participate in meetings (i.e., CMC, PRC, QIC), as assigned by Director of UM
  27. Attend and participate in health plan and regulatory agency (NCQA, DMHC) audits
  28. Participate in New Implementations (Program, Health Plan)
  29. Prepare Materials for Health plan and regulatory agency audits.
  30. Complete urgent and emergent risk assessments as needed
  31. Complete pre-certification for HLOC admissions as needed
  32. Assists with concurrent reviews as needed.
  33. Complete retro-reviews and retro-authorizations for inpatient or emergency services as needed

    Position Requirements:

    Education: Master's Degree in Psychology, Counseling, Social Work or related field

    Licensure: Valid CA State Clinical License required. Mental Health Clinical license, RN, LCSW, MFT, PHD, PsyD

    Relevant Work Experience: Current, valid and unrestricted licensure for independent practice (masters level) and minimum of five years' utilization management experience for all levels of care. Knowledge of medical necessity and treatment protocols for psychiatric and chemical dependency treatment.

    Knowledge, Skills & Abilities:
  • Leadership skills and supervisory experience, including ability to develop team performance
  • Experience in psychiatric/chemical dependency utilization management, preferably in a hospital and /or managed care setting
  • Excellent prioritization and organizational skills
  • Strong interpersonal skills and good written and verbal communication skills
  • Advanced level of PC skills required
  • Experience with staff supervision
  • Proven customer service skills
  • Ability to manage and coordinate with internal and external departments/customers
  • Must be detailed oriented; able to work independently
  • Good understanding of UM regulatory requirements (URAC, NCQA)
  • Ability to understand and interpret UM metrics as well as identify new UM metrics as needed
  • Understanding of clinical guidelines and level of care criteria
  • Good understanding of Utilization Management Standards, and Policies and Procedures

    TO APPLY

    Click below on "Apply for this Position" to create a profile and apply for the position

    Beacon Health Strategies, LLC., a Beacon Health Options company, is proud to be an Equal Opportunity Employer as well as a Drug Free Work Environment. EOE/M/F/Veterans/Disabled


AAP Reporting Location:

CA - Cypress

ID (Req #):

53439

FTE Status:

Full Time

Schedule:

Monday-Friday

PI100678581