RN Supervisor Utilization Management
at Dignity Health Medical Foundation
Rancho Cordova, CA 95670, USA -
Start Date | Expiry Date | Salary | Posted On | Experience | Skills | Telecommute | Sponsor Visa |
---|---|---|---|---|---|---|---|
Immediate | 12 Aug, 2024 | USD 69 Hourly | 13 May, 2024 | N/A | Management Skills,Leadership | No | No |
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Description:
POSITION SUMMARY:
Under the guidance and supervision of the department Manager/Director, the Supervisor of Utilization Management is responsible and accountable for coordination of services for Mercy Medical Group and Woodland Clinic Medical Group through an interdisciplinary process that provides a clinical and financial approach through the continuum of care. Promotes the quality and cost effectiveness of medical care by ensuring department staff are applying clinical acumen and the appropriate application of policies and guidelines to Managed Care prior authorization referral requests. Under general supervision this position is responsible for coordinating the daily operations of the UM Pre-Authorization team in order to ensure requests are processed in a consistent and timely manner while observing regulatory guidelines.
Responsibilities may include:
- Responsible for day to day operations of the Pre-Authorization team to include timely response and appropriate evaluation of referral reviews, correct selection of criteria, accurate prep to the UM Physician reviewer when indicated, timely verbal and written documentation, and completion of the file
- Ensures adequate staffing and assignments and adjusts workflow as needed to meet department goals.
- Assists manager with performance activities to include monitoring, coaching, educating, and providing feedback to team.
- Ensures UM Physicians are provided the relevant information needed to accurately review a referral. Fosters the relationship between the Pre-Authorization team and the Medical Director and Physician Reviewers.
- Tracks cost savings from activities over time to evaluate success of programs. Maintains or removes programs based on organization and department goals. Develops reports for leadership as required.
- Implements the Departments Policies and Procedures to remain in compliance with Regulatory Agencies (DMHC, DHS, CMS, NCQA, ICE)
- Supervises the use of established criteria sets (Medicare Guidelines, InterQual, Health Plan Benefit Interpretation Guidelines and Medical Management Policies, and DHMF Utilization Management guidelines and protocols.
- Works with other staff and references ICE to regularly ensure that all required forms and resource manuals are current, updated and in compliance with regulations.
- Coordinates completion of Peer InterRater on an annual basis and summarizes results for the UM Committee, initiating actions as requested.
- Proactively supports the Pre-Authorization team, department, and Organization, participates in all ad hoc meetings and prepares ad hoc reports.
Qualifications
MINIMUM QUALIFICATIONS:
- Five or more (5+) year’s clinical experience required.
- Three to five (3-5) years Utilization Management (UM) experience required.
- One to three (1-3) years charge/lead/supervisory/management experience required. Ablility to demonstrate leadership and management skills.
- Graduate of an accredited school of nursing.
- Clear and current CA Registered Nurse (RN) license.
PREFERRED QUALIFICATIONS:
- 7 years UM experience with Charge/Lead/Supervisory/Management experience in Utilization Management department preferred.
- Experience working with health plan auditors preferred.
- Bachelors of Science in Nursing and/or Master’s level degree preferred
LI-DH
Pay Range
$48.13 - $69.79 /hou
How To Apply:
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Responsibilities:
- Responsible for day to day operations of the Pre-Authorization team to include timely response and appropriate evaluation of referral reviews, correct selection of criteria, accurate prep to the UM Physician reviewer when indicated, timely verbal and written documentation, and completion of the file
- Ensures adequate staffing and assignments and adjusts workflow as needed to meet department goals.
- Assists manager with performance activities to include monitoring, coaching, educating, and providing feedback to team.
- Ensures UM Physicians are provided the relevant information needed to accurately review a referral. Fosters the relationship between the Pre-Authorization team and the Medical Director and Physician Reviewers.
- Tracks cost savings from activities over time to evaluate success of programs. Maintains or removes programs based on organization and department goals. Develops reports for leadership as required.
- Implements the Departments Policies and Procedures to remain in compliance with Regulatory Agencies (DMHC, DHS, CMS, NCQA, ICE)
- Supervises the use of established criteria sets (Medicare Guidelines, InterQual, Health Plan Benefit Interpretation Guidelines and Medical Management Policies, and DHMF Utilization Management guidelines and protocols.
- Works with other staff and references ICE to regularly ensure that all required forms and resource manuals are current, updated and in compliance with regulations.
- Coordinates completion of Peer InterRater on an annual basis and summarizes results for the UM Committee, initiating actions as requested.
- Proactively supports the Pre-Authorization team, department, and Organization, participates in all ad hoc meetings and prepares ad hoc reports
REQUIREMENT SUMMARY
Min:N/AMax:5.0 year(s)
Hospital/Health Care
Pharma / Biotech / Healthcare / Medical / R&D
Health Care
Graduate
Proficient
1
Rancho Cordova, CA 95670, USA