Manager, Utilization Management
Company: Dignity Health Management Services Organization
Posted on: June 8, 2021
The 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.
Dignity Health MSO offers an outstanding Total Rewards package
that integrates competitive pay with a state-of-the-art, flexible
Health & Welfare benefits package. Our cafeteria-style benefit
program gives employees the ability to choose the benefits they
want from a variety of options, including medical, dental and
vision plans, for the employee and their dependents, Health
Spending Account (HSA), Life Insurance and Long Term Disability. We
also offer a 401k retirement plan with a generous employer-match.
Other benefits include Paid Time Off and Sick Leave.
This role demonstrates expertise in conducting medical reviews
for necessity, level of care, and benefit reviews rendered in the
inpatient and outpatient setting to ensure the patient receives the
highest level of care. Coordinates with providers, provider staff,
and hospital staff, patients and patient family members to
establish an appropriate level of care.
- Analyzes inpatient clinical data and conducts skill nursing
facility level of care review on a concurrent basis. Refers cases
that do not meet the criteria to the Medical Director and UM
committee and assists in coordinating the review process.
- Refers known or suspected problems of under-utilization or
over-utilization or inappropriate scheduling of services to the
attention of the Medical Director, UM Committee and Quality
Management Department. Examples include avoidable bed days,
inappropriate admissions and delayed procedures.
- Provides technical support and serves as resource to PCP and
specialists offices, providers, and members regarding healthcare
needs and authorization process.
- Ensures identification of patients and maintenance of
information regarding high risk/high cost utilizers such as ESRD
patients, long-term care patients, third party liability patients
and transplant candidates.
- Identifies ways in which UM process impacts other departments
internally as well as external customers and works to facilitate
- Tracks barriers to appropriate inpatient and SNF utilization
according to policy and procedure.
- Attends Utilization Management and/or Quality Management
meetings as needed.RN, Registered Nurse, California License,
Managed Care, Hospital, Quality Management, QM, Quality Assurance,
QA, Supervisor, Manager, UM, Utilization Management, Inpatient,
Outpatient, CM, Case Management #QMNurse
Minimum Qualifications for success in this position
- Five or more years of experience working in a medical facility,
hospital, or other healthcare related environment.
- Minimum five years clinical experience, with at least two
years' experience working at a medical group or IPA performing
inpatient and/or outpatient utilization management functions with
managed care plans.
- One or more years' experience supervising the work of
- Valid CA driver's license, current DMV printout and insurance
- Must meet hospital credentialing requirements to obtain
Additional Required Qualifications
- Familiarity with regulatory requirements for managed care,
HMOs, and EPOs.
- Proficiency with health plan criteria/benefits and regulatory
requirements as they relate to patient management across the
continuum of care.
- Proficient with standardized criteria, Interqual/Milliman, MCG,
- Knowledge of network and benefit limitations and ability to
collaborate with stakeholders to find alternatives that meet
patient needs and achieve positive outcomes.
- Works collaboratively with the Authorizations/Utilization
Manager to create workflows that integrate the clinical and
technical aspects of the authorization process to ensure an
efficiently functioning UM system
- Knowledge of disease management strategies.
- Basic knowledge of CPT and ICD 9/ICD 10 codes and knowledge of
- Must be able to travel to locations within the local areas. May
require travel out of town, which may include overnight stays.
- Managed care experience preferred.
- Completion of
(Case management Certified),
(American Case Management) or other applicable certification
- Bachelor's degree preferred.
Keywords: Dignity Health Management Services Organization, Bakersfield , Manager, Utilization Management, Other , Bakersfield, California
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