Manager Outpatient Utilization Management / Job Req 939845760

Hybrid: Applicants must be a California resident as of their first day of employment.

PRINCIPLE RESPONSIBILITIES:

The Manager, Outpatient Utilization Management (UM) works under the direct supervision of the Director, Utilization Management. This position oversees the Outpatient Utilization Management (UM) team focusing on utilization management and care coordination to assure integration of all Health Care Services department operations. The Manager is responsible for policy and program development and implementation to assure quality care and cost effective services to members. This position is responsible for management and supervision of the outpatient UM team and maintaining strong working internal and external relationships.

Principal responsibilities include:

* Collaborate in implementing and monitoring departmental strategic plans for utilization management and care coordination.

* Develop and oversee systems for prior authorization requests, productivity metrics and meaningful management reports of both activities and outcomes. This will include analysis and reporting on utilization, health outcomes, care coordination and expenses with comparison to state and national standards and benchmarks.

* Conduct ongoing analysis that results in department changes to boost efficiency and effectiveness and align work processes with department goals and objectives.

* Assure staff and department compliance with all regulatory, contractual and accreditation requirements and provide documentation for audits, reviews.

* Review and update policies and procedures and assure consistency with regulations, contracts, Provider Manual, Evidence of Coverage and other plan documentation. This may be performed in conjunction with other managers and directors.

* Assist with preparation of the annual UM evaluation, UM Workplan , UM Program Description and other reports and presentations for internal and external departments and organizations as assigned.

* Work in a collaborative manner across the organization to achieve department and overall organizational goals.

* Work with the Director and Medical Director(s) to ensure appropriate clinical guidelines are developed and practiced, including participation in the review and maintenance of Prior Authorization rules

* Work with providers and delegated groups to educate on Outpatient UM processes including training on clinical processes as needed.

* Oversee clinical and non-clinical staff responsible for the processing and reviewing of prior authorization requests.

* Actively participate in recruitment, selection, and training of staff. Develop and communicate staff performance plans. Conduct annual performance appraisals. Implement corrective measures and discipline as necessary.

* Support and coordinate the day-to-day department activities by coaching and assisting the clinical and non-clinical staff.

* Be available to work alternative work week schedules, including weekends or holidays, as assigned, to ensure compliance with regulations

* Be available to provide on-site/ in-person support to the department, as needed

* Participate in efforts to implement technological enhancements for the unit.

* Maintain professional and technical knowledge.

* Perform other duties and special projects as assigned.

ESSENTIAL FUNCTIONS OF THE JOB

* Oversite and montioring of staff application of clinical guidelines to the review of authorizations andall utilization management processes to ensure complaince with all regulatory and accreditation standards.

* Developing and analyzing systems and processes to achieve quality and efficiency measures.

* Developing quantitative and qualitative management reports and analyzes data.

* Communicating effectively and efficiently internally and externally.

* Supervising and training of staff to include but not limited to team building, evaluations, corrective actions, and progressive discipline procedures.

* Writing, reporting, administration, and analysis.

* Developing verbal presentations.

* Leading and participating in internal and external committees and meetings.

* Complying with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

PHYSICAL REQUIREMENTS

* Constant and close visual work at desk or computer.

* Constant sitting and working at desk.

* Constant data entry using keyboard and/or mouse. Extensive typing required.

* Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.

* Occasional travel to office for meetings.

* Occasional walking and standing.

• Occasional driving of automobiles.

Number of Employees Supervised: 3 - 10

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

* BSN required.

* Registered Nurse license, active and unrestricted licensed in the State of California.

* Master's Degree or Doctorate preferred (MBA, MPA, MPH, MSN, or other applicable master's degree)

* Certification in applicable area preferred

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

* Minimum of five years of managerial/supervisory experience in utilization management/ clinical healthcare related experience required

* Minimum of three of the five managerial/supervisory years working within UM in the managed care environment required.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

* Knowledge of Medi-Cal and/or Department of Health Services and/or Medicare regulations and standards a plus.

* Ability to motivate, train, and supervise.

* Ability to make thoughtful decisions and exercise sound judgment.

* Experience with planning, implementing, and evaluating clinical and disease prevention programs a plus.

* Background in population-based community health assessment and interventions preferred.

* Ability to work effectively in a multidisciplinary approach in management.

* Ability to communicate effectively, both verbally and in writing.

* Experience in use of Microsoft Office suite.

SALARY RANGE: $142,043.20 - $213,075.20 ANNUALLY

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.