Manager, Utilization Review

Job Summary:

Under the direction and oversight of the Director of Utilization Management, the Clinical Manager, Utilization Review is responsible and accountable for coordination of services for members of River City Medical Group admitted to or discharged from an inpatient acute or skilled facility and/or outpatient services. The Clinical Manager, Utilization Review applies an interdisciplinary process that provides a clinical, production focused, efficient approach for concurrent review of services, treatment, admissions, outpatient services and discharges. The Clinical Manager, Utilization Review also establishes relationships with the community and providers and their staff to ensure provider and member satisfaction with the concurrent process.

Responsibilities:

• Ensures an effective interface and care integration of the UM program. 
• Maintains and improves UM communication and collaboration between, hospitals, skilled nursing facilities, hospitalists, health plans. Outpatient clinics, CCS and Sacramento County Medi-Cal members and the facilities where they receive care. 
• Conducts research and gathers/organizes data from a variety of sources for the identification of California Medi-Cal member quality, activities of daily living, health care issues, outpatient services, readmissions and discharge needs. 
• Formulate recommendations to implement solutions to address inpatient and outpatient management and transition to Outpatient Care Management (OP CM) or Complex Care Management (CCM) at the plan or medical group level as appropriate.
• Formulate recommendations to implement solutions to increase OP CM and CCM member opt in rates.
• Develops UM referrals, protocols, policies, and procedures to increase UM metrics.
• Monitors and Reports UM dash-board rates and metrics.
• Recruits staff and performance evaluation of UM staff.
• Assists in the development of performance standards for contracting potential UM paneled providers and facilities.
• Ensures that the UM Program complies with regulatory (i.e. NCQA) agencies and Medi-Cal and Milliman (MCG) admission guidelines and length of stay recommendations.   
• Ensures that all turnaround times(TAT) are being met.
• Ensures that staff are meeting program metrics including productivity.
• Responsible for performance improvement plans or corrective action plans as it applies to the UM staff. 
• Manages and directs the Company UM Program to ensure the consistent provision of quality health care services.  
• Maintains a performance standard that ensure successful and continued delegation of inpatient and outpatient concurrent review by the health plan.
• Responsible for health plan reporting, delegated functions for UM, and maintain communication with the health plans and contracted health providers and agencies.
• Assists in determining methods of accomplishing organizational performance objectives and increasing work efficiency for UM programs.  
• Assists in implementing new policies, work methods and work assignments for the clinical and non-clinical staff.
• Develops UM reports to ensure all cases are accurately updated and/or produced within established turnaround times.
• Maintains a well-documented procedure manual to include the job tasks of the UM Case Management Specialists, Coordinators, and clinical staff. 
• Reinforces clinical philosophy, programs, policies, and procedures.
• Communicates strategic plan and specific tactics to meet plan to staff. 
• Ensures implementation of tactics to meet strategic direction for evidence-based practice, medical necessity decision making without financial influence, and quality outcomes. 
• Creates direction and communicates a business case for change by focusing on and addressing key priorities to achieve business results. 
• Identifies opportunities to implement best practice approaches and introduce innovations to better improve outcomes. 
• Accountable for meeting the financial, operational and quality objectives of the unit. 
• Accountable for the day-to-day management of UM teams for appropriate implementation and adherence with established practices, policies and procedures if there is not supervisor position. 
• Works closely with functional area managers to ensure consistency in clinical interventions supporting our plan sponsors. 
• Develop, initiate, monitor and communicate performance expectations. 
• May act as a single point of contact for the provider and/or members which includes participation in provider or member meetings, implementation and oversight of member cultural requirements, and support implementation of new member groups or populations. 
• Responsible for the recruitment and hiring process for staff using clearly defined requirements in terms of education, experience, technical, and performance skills. 
• Assesses developmental needs and collaborates with peers, staff, and leadership to identify and implement corrective action plans and/or performance improvement activities that support the development of high performing teams. 
• Consistently demonstrates the ability to serve as a model change agent and lead change efforts. 
• Accountable for maintaining compliance with policies and procedures and implements them at the employee and/or team level. 
• Ability to evaluate and interpret data, identify areas of improvement, and focuses on interventions to improve outcomes.
• Performs related duties consistent with the scope and intent of the position.
• Regular attendance.
• Travel as required.

Other Functions

• Enforces Company policies and safety procedures.
• Regularly updates job knowledge by participating in educational opportunities, reading professional publications, maintaining professional networks, and participating in professional organizations.
• Maintain IPA, Health Plan compliance standards.

Competencies

• Five (5) to Seven (7) years professional nursing experience in an acute care setting or outpatient setting preferred or;
• Five (5) to Seven (7) years utilization/case management experience in the managed care industry a plus.
• Medicaid Experience a plus.
• Two (2) to Three (3) years direct supervisory and/or management experience, preferably within a managed care organization or medical group.
• Managed care experience or experience working in a provider office preferred
• Excellent communication skills, including both oral and written.
• Excellent active listening and critical thinking and analytical skills.
• Ability to solve advanced-level problems with minimal supervision.
• Has the ability to be a leader for the department, shows leadership skills and initiative. 
• Ability to multi-task, exercise excellent time management, and meet multiple deadlines.
• Ability to provide and receive constructive job and/or industry related feedback.
• Ability to exercise sound discretion and strict maintenance of confidentiality of all confidential and sensitive communications and information.
• Ability to consistently deliver excellent customer service.
• Excellent attention to detail and ability to document information accurately.
• Ability to effectively and positively work in a dynamic, fast-paced team environment and achieve objectives.
• Demonstrate commitment to the organization’s mission.
• Must have mid-level skills in Microsoft software (Word, Excel, PowerPoint, Visio) and Access is a plus.
• Typing speed of 40 wpm or more is a plus.
• Must have the ability to quickly learn and use new software tools.
• Must have mid-level skills using e-mail applications.
• Self-motivated with strong organizational, multi-tasking, planning, and follow up skills.
• Ability to work independently as well as in a team environment. 
• Ability to present self in a professional manner and represent the Company image. 
• Demonstrated leadership and project success are expected.

Education and Licensure

• Graduated from an accredited school of nursing required.
• Master’s Degree in Nursing or related field preferred.
• Current and Valid California License in the following disciplines is required:  Registered Nurse
• Public Health Certificate a plus

Travel

• The incumbent may travel up to 5% of the time.

Supervisor Responsibility

• This position supervises up to 5 employees in exempt/non-exempt positions.

Work Environment

This job operates in a professional office environment.  This role routinely uses office equipment such as computers, phones, photocopiers, scanners and filing cabinets.

Mental and Physical Demands

Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the position. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  While performing this job, the employee is regularly required to talk and hear.  The employee frequently is required to sit, stand; walk; use hands to finger, handle, or feel; and reach with hand and arms. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus. Experiences frequent interruptions; required to meet inflexible deadlines; requires concentration and attention to detail; requires a high level of organizational and prioritization skills. May be required to sit for prolonged periods; exposed to visual display terminal for prolonged periods; dexterity and precision required in the operation of a computer.