Manager, Utilization Management

Job ID
2020-133912
Employment Type
Full Time
Department
Utilization Review
Hours / Pay Period
80
Facility
Dignity Health Management Services Organization
Shift
Day
Standard Hours
Mon-Fri (8-5 PM)
Work Schedule
8 Hour
Location
CA-Bakersfield

Overview

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric, full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health’s Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups, hospitals, health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

 

Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art, flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options, including medical, dental and vision plans, for the employee and their dependents, Health Spending Account (HSA), Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.

 

 

Responsibilities

Conducts medical reviews for necessity, level of care, and benefit reviews rendered in the inpatient and outpatient setting to ensure the patient receives the highest level of care.  Coordinates with providers, provider staff, and hospital staff, patients and patient family members to establish an appropriate level of care.

  • Responsible for meeting all of the DHMSO Job Standards described below.
  • Plans for and ensures that all post discharge care is coordinated appropriately according to the needs of the patient and ensures continuity of care.
  • Conducts prior authorization review on all services that require nurse review.
  • Travels to various hospital within established areas to conduct patient visits.
  • Analyzes inpatient clinical data and conducts skill nursing facility level of care review on a concurrent basis. Refers cases that do not meet the criteria to the Medical Director and UM committee and assists in coordinating the review process.
  • Refers known or suspected problems of under-utilization or over-utilization or inappropriate scheduling of services to the attention of the Medical Director, UM Committee and Quality Management Department. Examples include avoidable bed days, inappropriate admissions and delayed procedures.
  • Provides technical support and serves as resource to PCP and specialists offices, providers, and members regarding healthcare needs and authorization process.
  • Ensures identification of patients and maintenance of information regarding high risk/high cost utilizers such as ESRD patients, long-term care patients, third party liability patients and transplant candidates. Identifies ways in which UM process impacts other departments internally as well as external customers and works to facilitate effective interactions.
  • Collects in-depth information about a patient’s situation and function. Identifies individual needs and develops comprehensive case management plan to address patient needs.  Creates plans that are action-oriented and time-specific.  Monitors care to ensure plan is achieving desired outcome, and makes revisions as needed to affect outcome.  Utilizes all relevant sources of information to ascertain the efficiency to the plan.
  • Coordinates all discharges from inpatient and skilled nursing facilities.
  • Makes outbound calls to patients according to care management queue assignment and care management policies and procedures.
  • Tracks barriers to appropriate inpatient and SNF utilization according to policy and procedure.
  • Attends Utilization Management and/or Quality Management meetings as needed.
  • Other duties as directed by supervisor or administration.

RN, Registered Nurse, California License, Managed Care, Hospital, Quality Management, QM, Quality Assurance, QA, Supervisor, Manager, UM, Utilization Management, Inpatient, Outpatient, CM, Case Management #QMNurse

 

#MISSIONCRITICAL

#DHLeader

Qualifications

 

  • Current California RN license required.
  • Five or more years of experience working in a medical facility, hospital, or other healthcare related environment.
  • Minimum five years clinical experience, with at least two years’ experience working at a medical group or IPA performing inpatient and/or outpatient utilization management functions with managed care plans.
  • One or more years’ experience supervising the work of others.
  • Valid CA driver’s license, current DMV printout and insurance required.
  • Must meet hospital credentialing requirements to obtain facility ID.

 

Additional Required Qualifications

  • Knowledge of nursing processes, care management, and continuity of care.
  • Familiarity with regulatory requirements for managed care, HMOs, and EPOs.
  • Ability to apply criteria to identify appropriate level of care on all admissions and clearly document any research conducted and rationale of decisions made.  Ability to identify care needs across the age continuum and according to principles of growth and development over the life span.
  • Ability to apply appropriate business rules, medical guidelines and/or health plan benefits to authorization decision making.
  • Proficiency with health plan criteria/benefits and regulatory requirements as they relate to patient management across the continuum of care.
  • Proficient with standardized criteria, Interqual/Milliman, MCG, Medicare, etc.
  • Knowledge of network and benefit limitations and ability to collaborate with stakeholders to find alternatives that meet patient needs and achieve positive outcomes.
  • Works collaboratively with the Authorizations/Utilization Manager to create workflows that integrate the clinical and technical aspects of the authorization process to ensure an efficiently functioning UM system
  • Knowledge of disease management strategies.
  • Basic knowledge of CPT and ICD 9/ICD 10 codes.
  • Ability to interpret and communicate complex contract or benefit language.
  • Willingness to work as part of a team, working collaboratively with others to achieve goals, solve problems, and meet established organizational objectives and management of patients.
  • Excellent communication skills, able to read, write, and speak articulately using established channels of communication and reporting relationships within the organization. Able to communicate effectively with all levels of internal/external staff, management, members, physicians/physician office staff, families of members, outside agencies, etc.
  • General knowledge of Microsoft Office applications; Excel, Word, Outlook; experience with DHMSO Online, QNXT.
  • Ability to handle various situations in a professional manner, demonstrating excellent customer service at all times.
  • Ability to demonstrate respect for the feelings and needs of patients, family members, team members, visitors, and others with sensitivity to their cultural, language, financial, physical, and social differences.
  • Strong problem-solving abilities. Ability to identify issues and problems within administrative processes, activities, and other relevant areas.
  • Ability to continually re-prioritize to meet the needs of internal and external customers throughout the workday. Ability to adapt to change quickly.
  • Must be attentive to detail, accurate, thorough, and persistent in following through to completion of all activities, demonstrating initiative for completing work assignments.
  • Must be able to travel to locations within the local areas. May require travel out of town, which may include overnight stays.
  • Ability to use the following general office equipment correctly and safely: desktop computer for data entry and typing, copy machine, scanner, and facsimile machine, and telephone equipment.
  • Ability to be reliable in attendance and timeliness to work schedules.
  • Ability to adhere to dress code, good grooming, and personal hygiene habits.
  • Ability to maintain knowledge of and conform to company policies and procedures.
  • Ability to maintain strict confidentiality at all times.

 

Preferred Qualifications

  • Managed care experience preferred.
  • Completion of case management certificate preferred.
  • Bachelor’s degree preferred.

 

 

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