Manager, Utilization Management

Overview:

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.

Responsibilities

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 effective interactions.
• 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

#missioncritical

#casemanagement

#utilizationmanagement

#MISSIONCRITICAL

#DHLeader

Qualifications

Minimum Qualifications for success in this position include:

• 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 others.
• Valid CA driver's license, current DMV printout and insurance required.
• Must meet hospital credentialing requirements to obtain facility ID.

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, Medicare, etc.
• 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 QNXT.
• Must be able to travel to locations within the local areas. May require travel out of town, which may include overnight stays.

Preferred Qualifications

• Managed care experience preferred.
• Completion of
  CCM
  (Case management Certified),
  ACM
  (American Case Management) or other applicable certification preferred.
• Bachelor's degree preferred.

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