Job Summary and ResponsibilitiesAs our RN Supervisor of Utilization Management Pre-Service (Clinical), you will have well-developed knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. You will support the UM pre-service program by supporting assigned direct leadership and lead assigned personnel.
Every day you will be responsible for ensuring staff perform a variety of pre-service UM-related reviews and functions while ensuring appropriate data is tracked, evaluated, and reported. You will supervise, lead and/or actively participate in process improvement initiatives, working with a variety of departments and multi-disciplinary staff.
To be successful in this role, you will maintain current and accurate knowledge regarding commercial, government payers and NCQA regulations/guidelines/criteria related to UM.
As a remote employee, we will provide you with the equipment needed to work from home, including a laptop, docking station, dual monitors, and accessories.
This position is remote, but will be expected to work PST business hours.- Direct leadership oversight of assigned teams; direct reports related to the clinical pre-service function of UM. Supervise Utilization Management Nurses, Coordinators, including timely performance evaluations, disciplinary actions and identification of training needs.
- Support direct manager, UM Pre-Service Director and Delegation Oversight team in the development and/or updating of departmental manuals, procedures and processing standards relative to the authorization process.
- Maintain authorization production standards and statistics, ensuring production meets timeliness goals established by CMS, DMHC, NCQA, DHCS and Health Plans; reports to management on a daily basis.
- Develops, implements, and/or monitors standardized protocols for clinical team activities to facilitate integrated proactive case management.
- Works as a liaison with external organizations to assure lines of communication are in place and communicates directly with physicians, and community providers as needed.
- Makes staff assignments. Evaluates staff and determines the quality of their work efforts.
Job RequirementsRequired- Minimum of 3 years' recent clinical experience
- Experience supervising staff and monitoring productivity/performance
- Clear and current CA Registered Nurse (RN) license
Preferred- UM Pre-Service/Prospective Review experience strongly preferred
- Minimum of 3 years' experience in IPA or managed care setting preferred
- MCG Criteria application experience preferred
Where You'll WorkThe purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric, full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health's Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups, hospitals, health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.
One Community. One Mission. One California
