Director, UM - RN

Job Description

Job Description

JOB DESCRIPTION

JOB TITLE: Director, UM - RN FLSA STATUS: Exempt

DEPARTMENT: Utilization Management

REPORTS TO: Chief Medical Officer

AUTHORITY : Clinical and non-clinical staff

JOB SUMMARY: Responsible for providing operational leadership to the day-to-day function of the UM/Prior Authorization and Inpatient Teams. The UM Manager will ensure that the team complies with Federal, State, Health Plan and NCQA requirements

ESSENTIAL JOB FUNCTIONS:

1. Collaborating with clinical and non-clinical personnel providing timely care which complies with generally accepted standards of clinical practice.

2. Assigns work schedules, delegates reviews, provides direction on review priorities, meets the demands of internal and external partners, and ensures staff achieve performance goals and adherence to company policies.

3. Ensures that the UM team is properly trained to conduct medical necessity reviews on incoming pre-service/prior authorization, on routine and expedited referrals requests in compliance with Federal, State, Health Plan and NCQA standards.

4. Ensures UM team documents on the medical management system timely, all supporting clinical information, outreach attempts and criteria used to make a determination.

5. Monitors, tracks, and reports any inappropriate referral patterns to the UM Medical Director and Director of Clinical Services

6. Serves as a subject matter expert on appropriate use, interpretation and documentation of clinical criteria in the review process using NCD, LCD, Health Plan Medical Guidelines, MCG, NCCN, etc.

7. Conduct inpatient huddles to review inpatient census including Inpatient CMs and CMO to discuss cases and discuss barriers of discharge plannings.

8. Conduct Annual IRR Reviews for clinical staff by using selecting case studies via MCG Learning Module.

9. Conduct Annual IRR Reviews for non-clinical staff by administering quiz.

10. Prepare and participate in UM audits.

11. Develop and revising UM program, workplans and policies and procedures.

12. Prepare and update quarterly, semi-annually and annual um workplans.

13. Participate in MSC meetings and other meetings as needed.

14. Prepare and submit compliance reports related to UM activities.

15. Correspond promptly to health plan requests that are related to um activities.

16. Facilitates an atmosphere of interactive management and the development of collegial relationships among personnel and others, serving as a link between clinical and the healthcare disciplines

17. Collaboration with clinical personnel and members of other disciplines, participates in an organizational policy and procedure formulation and decision making, accepts organizational accountability for services provided, and evaluates the quality and appropriateness of care.

18. Maintains regular and consistent attendance.

19. Adheres to Compliance Plan and HIPAA regulations.

MARGINAL JOB FUNCTIONS:

1. Takes on special projects as needed.

2. Performs other duties as assigned.

BEHAVIORAL EXPECTATIONS:

1. Continuous Learning:

a. Attends staff meetings as required.

b. Attends appropriate training, seminars and workshops as required

2. Customer Focus:

a. Maintains client/customer confidentiality and privacy in accordance with HIPPA regulations

and IMAS’s Standards of Conduct.

b. Fosters appropriate communication and relations with Supervisor, co-workers and other staff.

3. Quality/Process Improvement/Safety

a. Reports issues of security, health and/or safety to appropriate supervisor as soon as practicable.

b. Supports and demonstrates safety throughout all duties performed.

c. Follows established policies and procedures and understands and complies with all regulators

standards set forth by governing entities.

POSITION REQUIREMENTS:

EDUCATION/EXPERIENCE:

· Bachelor’s degree in a health care related field

· At least 5+ years of management experience in a Medical Group, MSO, Hospital, or Health Plan setting with experience in operational/production management

· At least 5 years of experience in UM/Managed Care setting

· EZCap experience

SKILLS/KNOWLEDGE/ABILITY:

· Proficient in Microsoft Suite: Outlook, Word, Excel

· Willingness and ability to read, write, speak, understand English and have the communications skills necessary to provide accurate information to members and staff.

· Willingness and ability to follow written and verbal direction in English.

· Willingness and ability to maintain appropriate level of confidentiality and privacy.

· Willingness and ability to interact professionally with all customers, members, and co-workers, individually and as part of a team.

· Willingness and ability to effectively handle multiple items/tasks as required and adapt favorably to changing priorities.

· Willingness and ability to make appropriate judgments, decisions and problem solving in a timely manner and within the context of the situation at hand.

· Ability to effectively prioritize items/tasks as required.

· Willingness and ability to take initiative and be a self-starter.

· Willingness and ability to understand and comply with Federal, State, and local regulations.

LICENSURE/CERTIFICATE/TRAINING:

· Registered Nurse (RN) in the State of California, additional licenses in State of Texas and Arizona will be a plus