Description: Developing, managing and providing the Utilization Management programs in a service area or medical center. Develops and manages programs that emphasize appropriate admissions as well as concurrent and retrospective review of care. May also be responsible for other integrated functions such as Discharge Planning, Case Management Program, Outside Utilization Review program, Transportation coordination and Extended Care Coordination to promote a centralized, coordinated interdisciplinary process in the continuum of care.
- Oversees adherence to quality of care and utilization standards by reviewing documentation and analysis of utilization data.
- Develops standards of care and quality improvement activities based on regulatory standards.
- Serves as a resource to senior management as UM and CM experts.
- Develops regional programs based on regulatory requirements.
- Collaborates with program re-design to meet targeted utilization outcomes.
- Provides clinical and regulatory expertise for contractual reviews and for regional regulatory surveys.
- Provides oversight to design, develop, implement and monitor UM and Case Management programs to meet regional utilization goals while maintaining customer satisfaction.
- Acts as a resource to Directors, Assistant Administrators, Ambulatory Medical Staff, SCPMG and external regulatory agencies for all issues relating to UM.
- Analyzes and reports significant utilization trends, patterns and impact to appropriate departments.
- Serves as a contract liaison for regional issues pertaining to contracts and vendor, outside medical and transportation.
- Provides education and training to UM Directors, Physicians and Case Managers to ensure smooth operations in UM and CM.
- Makes significant contributions and or provides clinical and technical leadership to high visibility projects to identify and resolve issues of strategic importance to the organization.
- Interfaces regularly with senior management to produce timely and valuable results.
- Sets the strategic direction of projects.
- Determines goals and priorities with management team sponsor.
- Establishes team membership and negotiates time commitments and resources.
- Develops proposals for clients outlining proposed project structure, approach and work plan.
- Provides staff leadership to project teams, as well as manages work of outside consultants when needed.
- Designs research plans for data gathering and analysis; participates significantly in interpreting analysis and developing action plans accordingly.
- Produces or oversees development of written materials for senior executives and other key clients.
- Compliance and Integrity: Models and reinforces ethical behavior in self and others in accordance to the Principles of Responsibility; adheres to organizational policies and guidelines; supports compliance initiatives; maintains confidences; admits mistakes; conducts business with honesty; shows consistency in words and actions; follows through on commitments.
- Minimum five (5) years of experience in a clinical setting.
- Bachelor's degree in nursing or business administration, health care administration or public health administration or other related field required.
License, Certification, Registration
- Current California RN License required.
- Demonstrated ability to determine the key business issues and develop appropriate action plans from multidisciplinary perspectives.
- Demonstrated ability to conduct and interpret quantitative/qualitative analysis.
- Proven leadership skills in project management and consulting. Must exhibit efficiency, collaboration, and candor, openness, and results orientation.
- Demonstrate knowledge of the Nursing Practice Act; TJC, NCQA, Title 22, Federal and State Health Regulatory requirements, operations of KP health policy trends.
- Must be able to work in a Labor/Management Partnership environment.
Job Number: 633095