POSITION SUMMARY: The UM Supervisor is responsible for supervising utilization review activities for Medi-Cal managed care and dual eligible (Medicare & Medi-Cal) enrollees. The UM Supervisor provides support to the Medical Management staff, develops and maintains databases, produces and distributes reports, and supports utilization management training and operational needs.
Principal accountabilities: • Plans, organizes and oversees the non-licensed staff to provide first-line, day to day, supervisory oversight for UR activities. • Is knowledgeable about Centers for Medicare and Medicaid rules, and pertinent state and federal regulations. • Demonstrates a comprehensive understanding of contracts, including division of financial responsibility (DOFR) and how they pertain to UR determinations. • Collaborates and communicates regularly with contracted health plans, ancillary vendors, and multiple internal department leaders • Knowledgeable of ICE, health plan, CMS regulations, NCQA and other relevant industry standards • Evaluates accuracy, productivity, timeliness and ensures customer satisfaction. • Performs regular audits of authorizations and referrals • Oversees referral process and supportive documentation for UM work requiring Medical Director review • Participate in UM department data collection, QA, audits, reporting and analysis • Ensures department activities and records are in adherence with ICE and health plan regulatory requirements. • Assists with identifying patterns and trends, and develops and implements corrective action plans. • Identifies and develops and managed project plans and other necessary project tools with identification of key stakeholders. • Supports Director in interdepartmental communications and collaboration
Experience: • Previous management or administrative experience preferred • Experience within a health care setting, Experience in IPA/medical group preferred • Experience in utilization management preferred • Proficient application of multiple computer software products preferred.
Knowledge: • Excellent analytical and organizational skills • Must have excellent leadership, team management and relationship building skills, solid problem solving skills and ability to focus both strategically and tactically to achieve business goals • Working knowledge of medical terminology and coding (e.g., ICD-9, CPT-4, and HCPCS) preferred • Ability to maintain the integrity of confidential information • Knowledge of data collection techniques and methods of analyzing and reporting data. • Requires ability to be self-directed and work independently, have excellent business and communications skills (written and verbal) and the ability to manage communications up and down Special Skills/Equipment: • PC proficiency in word processing, spreadsheets, graphics, flow charts, organizational charts, and database software applications required • Microsoft products preferred (Windows, Word, Excel, PowerPoint, Access, and Exchange)
Qualifications: • Current CA Registerd Nurse licensure required - Experience in one or more of the following: Utilization Management, Health plan, Medicare, Medi-Cal • Superior verbal and written communication skills, organizational and analytical abilities are required. • Excellent telephone and active listening skills are essential • Speaks another language preferred
HIPAA Designated Access - “For the purposes of the job duties of this position, the person in this position requires access only to the following HIPAA protected information data sets”
X 1. MSO Membership X 2. MSO Claims X 3. MSO Referral/Auth X 4. MSO Capitation X 5. Data Warehouse X 6. Chart Audit/QI X 7. Disease Registry
Mental and Physical Demands: Pace of Work: Steady pace, at times fast to meet deadlines or when working under short notice. Concentration: Steady Standing Time Required: Minimal about 20-25% Time Speaking and Listening: 50% Environmental and Health Hazards: Minimal. Will face job stress periodically.
Salary and Benefits This is a full time position. CHCN offers a competitive salary and benefits package.
The Community Health Center Network is an Equal Opportunity Employer.
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