Utilization Management Director
Company: AltaMed Health Services Corporation
Location: Montebello
Posted on: July 28, 2022
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Job Description:
Overview:
The Utilization Management Director (UMD) position is responsible
for the development and implementation of AltaMeds utilization
management strategic plan, by providing leadership, direction and
support for Utilization Management (UM) functions that focus on the
evaluation of medical necessity, appropriateness, and efficiency of
the use of health care services, procedures, and facilities under
the provisions of the applicable health benefits plan and in
compliance with industry regulatory provisions as they pertain to
UM delegation.The UMD provides oversight of the utilization review
staff and determines policies and procedures that incorporate best
practices in conducting concurrent reviews, prior authorizations
and or retrospective activities that are predicated on ensuring
member care coordination is conducted timely, in the right setting,
and is cost-effective and quality driven. UMD leadership is
incumbent on providing a functional UM infrastructure that is
fundamentally driven through staff education, training and the
provision of adequate resources to effectuate optimal outcomes in
productivity and excellence. The Director measures UM activities
outcomes through the application of innovative strategies and
analytics to support the measurement of UM trends, patterns, and
impacts to resources to validate they are meeting UM goals and
objectives.
Responsibilities:
Develop UM goals and objectives in accordance with
companystandards.Assist in coordinating integration between medical
management delegated activities, IPA and contracted Health
Plan.Monitor and analyze the managed care operations productivity
and quality while providing ongoing feedback and education for the
staff.Assist in coordinating integration between medical management
delegated activities, IPA and contracted Health Plan. Monitor and
analyze the productivity and quality of these managed care
operations while providing ongoing feedback and education for the
staff.Plans, directs and monitors the utilization management
program(s). Provides advice, counsel, feedback and coordination to
promote a collegiality between staff, physicians and the leadership
team.Ensures that development of care coordination across the
continuum leads to outcomes supportive of industry
standards.Designs and implements processes to ensure appropriate
care coordination in accordance with quality and safety.Provides
direction for performance measures to attain optimal clinical,
operational, financial and satisfaction outcomes.Directs the
collection, analysis and presentation of data on utilization
patterns and outcomes.Manages the financial and capital resources
for UM services by monitoring operating revenue and expenses,
establishing and maintaining cost control programs and developing
and implementing new or revised programs and/orservices.Provides
oversight of all referral/authorization, of prior authorization,
inpatient concurrent review and retrospective reviews.Develops and
implements strategies to work with all external customers to ensure
appropriate reimbursement.Develops and oversees the department
budget in conjunction with corporate goals andobjectives.Perform
all other related duties as assigned.Prior AuthorizationEnsures
timely ongoing authorization requests review in alignment with
health plan contractual requirements and regulatory mandatesEnsures
appropriate usage of resources to facilitate the UM
processIdentifies opportunities for process improvements necessary
to facilitate department functionsHandles escalated cases either
internally or those referred by contracted providers.Works closely
with Regional Medical Directors to manage business need for UM
operationsAssists with the review and development of new protocols,
procedures and guidelinesParticipates in onsite and webinar
CMS/health plan audits as subject matter expert on UM policies,
standards and compliance for UM operationsResponds timely to
corrective action plans and all follow-up activityWorks closely
with all clinical personnel making UM decision to ensure compliance
with application of medical necessity and benefits
interpretationWorks closely with leadership on UM initiatives to
ensure regulatory complianceInpatientResponsible for the oversight
of concurrent reviews for medical necessity per evidenced based
criteria, appropriateness of service and level of care and
validated through UM documentation practices of assigned
staffResponsible for ensuring the concurrent review process is
conducted timely and in accordance with regulatory
standards,Responsible for overseeing staff functions supporting
timely arrangements for transitions to higher or lower level of
careResponsible for ensuring that the concurrent process includes
referring cases that require clinical consultation with the Medical
Director in a timely manner and per assigned rounds
schedule,Responsible for implementing systems and processes that
support identifying outliers and preparing documentation as well as
reports on potential quality of care issues as identified.Serve as
the liaison between hospitals, IPAs, vendors, outside agencies, and
providers to ensure effective communication and collaboration in an
effort to support an effective review processes throughout the
institutional continuum of care,Ensure the privacy and security of
PHI (Protected Health Information) as outlined in company policies
and procedures relating to HIPAA compliance.
Qualifications:
Bachelors degree in Nursing preferred, plus a minimum of five years
experience in managed care at the hospital or insurance industry
level with at least 2 years of experience in a supervisory capacity
or its equivalent required.Experience in managing employees in
remote locations highly desirable.Current valid license as a
registered nurse through the California Board of Registered Nursing
required.Knowledge of clinical care practices, operations and
local, state and federal regulatory standards.Experience with
E.H.R. and utilization management IT systems highly
desirable.Knowledge of UM Policy and Program development and
application required.
Keywords: AltaMed Health Services Corporation, Montebello , Utilization Management Director, Executive , Montebello, California
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