Utilization Management Manager
Company: Community Health Group
Location: Chula Vista
Posted on: August 6, 2022
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Job Description:
EEO1: First/Mid-level Officials and Managers POSITION SUMMARY:
The Utilization Management Manager orients, guides and oversees the
Inpatient and Outpatient case managers. The role is to plan,
develop, implement, evaluate and refine case management
intervention. This individual supervises the case management and
concurrent review personnel and ensures that they assess, plan and
deliver care appropriate to the age specifics of every member and
to all others involved within the job structure. COMPLIANCE WITH
REGULATIONS Works closely with all departments necessary to ensure
that the processes, programs and services are accomplished in a
timely and efficient manner in accordance with CHG policies and
procedures and in compliance with applicable state and federal
regulations including CMS and/or Medicare Part D and Special Needs
Plan (SNP). RESPONSIBILITIES Supervises the case managers and
concurrent review nurses in the performance of their role and
position description. Assists the case managers in the coordination
of care and service of a selected client population across the
continuum of illness. Formulates, implements, and evaluates the
knowledge base of the case managers and concurrent review nurses in
the performance of their position description. Analyzes the case
management goals for the members, reviews the plan for its
appropriateness, and reviews and identifies anticipated outcomes.
Develops and maintains a positive work climate that supports the
overall staff efforts at CHG. Assists in developing the philosophy,
goals, and objectives for concurrent case management performance
that meets clinical and financial requirements. Anticipates,
recommends, implements, and evaluates policies and procedures
related to case management and concurrent review. Contributes to
the organization's goals and objectives; supports the
organizational strategic plan. Actively participates in the
development of clinician guidelines and incorporates the process
into the role of the case managers. Interfaces with external
agencies and provides appropriate information, consultation, and
recommendations. Supports the culture of continuous quality
improvement. Uses quality improvement tools and strategies in
problem-solving activities. Identifies patterns or trends in case
management that have or had the potential for adverse impact on
member interventions. Develops corrective action plans and
reevaluation of outcomes. Attends educational and training programs
to expand knowledge. Works on assigned projects as requested.
EDUCATION BS in Nursing Masters in Nursing preferred.
EXPERIENCE/SKILLS 3 years of clinical nursing; 2 years of UM/UR
experience 2 years of experience in managed care preferred. CPT and
ICD9-CM coding; M&R and/or other UM criteria; Microsoft Office
software or equivalent; knowledge of applicable state and federal
laws and NCQA; working knowledge of Medicaid, CCS required.
Experience in interpreting Utilization and benefits data. Strong
communication skills; analytical; ability to organize work
effectively, determine priorities; works well independently and as
a team player. Skilled and proficient in applying highly technical
principles and concepts. Demonstrated ability to interact with a
wide variety of individuals and to handle complex situations
simultaneously. PHYSICAL REQUIREMENTS Utilizing computers over
prolonged periods of time. Must maintain confidentiality; may be
necessary to work and attend meetings outside facility or normal
business hours; may be required to work evenings and weekends.
Employment Type: Full Time Years Experience: 5 - 10 years
Bonus/Commission: No
Keywords: Community Health Group, Chula Vista , Utilization Management Manager, Executive , Chula Vista, California
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