Under direction from the Director of Utilization Management, manages and provides direction to the Health Services department Managers for all product lines ensuring consistent development, implementation, and maintenance of health services programs and achievement of department goals and objectives, in a fast paced, ambiguous environment. Ensures compliance with established criteria and Partnership benefits.

• Provides day-to-day direction to Utilization Managers and Supervisors to meet department goals and objectives.
• Responsible for ensuring performance evaluations are completed appropriately in a timely manner.
• Participates in the grievance process
• Coordinates activities with Member Services, Claims, and Provider Relations departments to identify, track, and monitor quality of care issues and trends.
• Responsible for establishing and maintaining reports that will support the efficacy of each Utilization Management (UM) activity and to produce a summary at least annually or upon request that includes statistical reports of activity, quality improvement activities, and utilization outcomes.
• Provides oversight and monitoring of the medical claims review and appeals to ensure timely accurate response.
• Provides direction and oversight to ensure efficient and appropriate collaboration between the Utilization Management staff and the delegated mental health provider and other internal and external organizations.
• Ensures that all policies and procedures are updated at least annually or as needed and presented to appropriate committees for review.
• Participates in annual delegation audits for UM, prepares report for presentation to Director of Utilization Management and responsible Committees.
• Works with all other departments to resolve claims, UM, QI, and member issues as necessary.
• Reports any issues with regulatory compliance to Director of Utilization Management and assists in design and implementation of a corrective action plan as necessary.
• Prepares reports on departmental activities according to established schedules and format. Identifies patterns and trends and works with Managers to develop corrective action plans.
• Works with Managers, Supervisors, and Trainer to develop standardized training content and material for new staff and for the ongoing education of existing staff.
• Provides oversight of training program to ensure adequate training accomplishes objectives and results in staff competency.
• Conducts retrospective review, either in the aggregate or on an individual basis, as needed. Provides summaries of findings to the Director of Utilization Management as requested.
• Assists Partnership staff and providers with the interpretation of Partnership policies, procedures, and regulatory requirements for all product lines.
• Promotes the continuous improvement process and implements recommended changes.
• Participates in all cost containment efforts of both the Health Services department and Partnership.
• Develops annual goals for individual performance and updates at least every six (6) months for progress
• Works with other departments within Partnership to develop and implement improvements that will lead to improved performance or enhanced workflow of staff.
• Participates in the planning of new enhanced Health Services products.
• Participates in onsite audits by various regulatory agencies as necessary.

SECONDARY DUTIES AND RESPONSIBILITIES

• Leads, assigns, and participates in special projects and assignments as required.

Education and Experience

Bachelors degree in Nursing required. Minimum five (5) years of clinical experience; three (3) years of managed care (utilization or case management) experience; minimum three (3) years of management experience in a medical management setting, with effective problem solving in an area where few precedents have been set; or equivalent combination of education and experience.

Special Skills, Licenses and Certifications

Current California Registered Nurse license. Effective telephone and computer skills required. Working knowledge and experience with ICDCM and CPT coding schemes. Thorough knowledge of utilization and case management programs and application of related clinical criteria and protocols. Knowledge of and experience with Federal Medicaid and/or California Medi-Cal programs preferred. Ability to work effectively across departments and functions within the organization. Competency with PCs and medical management software, word processing, spreadsheets, etc. Valid California drivers license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business.

Performance Based Competencies

Demonstrated effective leadership and analytical skills. Effective oral and written communication skills. Excellent interpersonal skills.

Work Environment And Physical Demands

Ability to use a computer keyboard. Ability to prioritize workload and initiate action to acquire needed information from professionals by phone. Ability to function effectively with frequent interruptions and direction from multiple team members. More than 50% of work time is spent in front of a computer monitor. Must be able to lift, move, or carry objects of varying size, weighing up to 10 lbs.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlans policies and procedures, as they may from time to time be updated.

HIRING RANGE

$ 162,227.25 - $ 210,895.42

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.