Manager, Utilization Management

Job ID
2021-164856
Employment Type
Full Time
Department
Utilization Review
Hours / Pay Period
80
Facility
Dignity Health Management Services Organization
Shift
Day
Standard Hours
Monday- Friday 8am-5pm
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

The Manager, Utilization Management 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.

Qualifications

The Manager, Utilization Management will analyze inpatient clinical data and conduct skill nursing facility level of care review on a concurrent basis. 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. 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. 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

 

 

 

Required:

 

-Current California RN/LVN license required.

 

-Valid CA drivers license, current DMV printout and insurance required.

 

-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.

 

-Must meet hospital credentialing requirements to obtain facility ID.

 

 

Preferred:

 

-Bachelors degree preferred.

 

-Managed care experience preferred.  

 

 

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