Manages the day-to-day operations of the Utilization Management Program in the Service Area or a Medical Center. Ensures cost effective and quality patient care by appropriate utilization of resources. Provides direction to staff which may include Outside Utilization, Extended Care, Bed Placement, Discharge Planning, Transportation and others as assigned.
Essential Responsibilities:
Assists in developing and maintaining policies and procedures for the Service Area or Medical Center related to Utilization Management.
Collaborates with the multi-disciplinary teams to plan and coordinate care across the continuum.
Coordinates and manages members care with non-KFH hospital facilities and providers. Identifies risk management and quality of care issues across the continuum.
Surfaces issues and any suggestions to the appropriate multi-disciplinary team members.
Manages transportation program to ensure appropriate utilization of resources which meet Health Plan guidelines and patient needs.
Assures compliance with Federal, State, TJC, NCQA, other regulatory agencies and internal standards and requirements.
Provides direction to staff regarding utilization review, care coordination, discharge planning, and other services across the continuum of care.
Assists in conducting statistical studies in utilization trends, patterns, and outcomes.
Hires, trains coaches, disciplines professional and clerical support staff.
Basic Qualifications:
Experience
Minimum three (3) years of experience in utilization management and discharge planning in an acute care setting to also include supervisory or management experience.
Education
BSN or bachelors degree in healthcare related field such as management, health services administration.
License, Certification, Registration
Registered Nurse License (California)
Additional Requirements:
Demonstrated knowledge of operations and healthcare management; TJC, Title XXII, Medicare, MediCal and other local, state and federal regulations.
Knowledge of managed care operations.
Demonstrated interpersonal, negotiation, and management skills.
Good oral and written communication skills.
Must be able to work in a Labor/Management Partnership environment.