RN Supervisor UM Prior Auth

CommonSpirit Health•Rancho Cordova, CA

6d•Hybrid

About The Position

As the Supervisor of Utilization Management (UM), under the guidance and supervision of the department Manager/Director, you will be responsible and accountable for coordination of services for Mercy Medical Group and Woodland Clinic Medical Group through an interdisciplinary process that provides a clinical and financial approach through the continuum of care. Promoting the quality and cost effectiveness of medical care by ensuring department staff are applying clinical acumen and the appropriate application of policies and guidelines to Managed Care prior authorization referral requests. Under general supervision, this position is responsible for coordinating the daily operations of the UM Pre-Authorization team in order to ensure requests are processed in a consistent and timely manner while observing regulatory guidelines. Responsible for day to day operations of the Pre-Authorization team to include timely response and appropriate evaluation of referral reviews, correct selection of criteria, accurate prep to the UM Physician reviewer when indicated, timely verbal and written documentation, and completion of the file. Ensures adequate staffing and assignments and adjusts workflow as needed to meet department goals. Manages team schedule including requests for time off and assurance of coverage during physician office hours. Organizes, structures, and chairs a minimum of one pre-authorization meeting per month, including other staff as appropriate. Motivates and coaches staff to include new-hire training, problem solving, and special projects. Assists manager with performance activities to include monitoring, coaching, educating, and providing feedback to team. Ensures UM Physicians are provided the relevant information needed to accurately review a referral. Fosters the relationship between the Pre- Authorization team and the Medical Director and Physician Reviewers. Tracks cost savings from activities over time to evaluate success of programs. Maintains or removes programs based on organization and department goals. Develops reports for leadership as required. This position is hybrid, work-from-home and in-clinic/office. This position will work rotating weekends.

Requirements

5+ years clinical experience.
3+ years Utilization experience in health plan/UM operations, Acute or subacute utilization review.
Bachelors degree, or equivalent experience.
Clear and current CA Registered Nurse (RN) license.
Ability to demonstrate leadership and management skills.
Knowledge of all applicable federal and state regulations as well as accreditation standards.
Demonstrates a working knowledge of Utilization Management, UM review processes, and regulatory requirements.
Must have the ability to monitor, compile, report and analyze data/statistics.
Requires excellent human relations, interpersonal and oral/written communication skills.
Able to recognize and address the needs and concerns of customers.
Ability to interact with all levels of the organization as well as with external contacts.
Requires good knowledge and skills with Microsoft Office (ie: Word and Excel) and other computer information systems and applications.

Nice To Haves

7 years UM experience with Charge/Lead/Supervisory/Management experience in Utilization Management department preferred.
Experience working with health plan auditors preferred.
Working knowledge of InterQual preferred.
Knowledgeable of NCQA and ICE preferred.

Responsibilities

Coordination of services for Mercy Medical Group and Woodland Clinic Medical Group
Ensuring department staff are applying clinical acumen and the appropriate application of policies and guidelines to Managed Care prior authorization referral requests
Coordinating the daily operations of the UM Pre-Authorization team
Ensuring requests are processed in a consistent and timely manner while observing regulatory guidelines
Day to day operations of the Pre-Authorization team to include timely response and appropriate evaluation of referral reviews, correct selection of criteria, accurate prep to the UM Physician reviewer when indicated, timely verbal and written documentation, and completion of the file
Ensuring adequate staffing and assignments and adjusts workflow as needed to meet department goals
Managing team schedule including requests for time off and assurance of coverage during physician office hours
Organizing, structures, and chairs a minimum of one pre-authorization meeting per month, including other staff as appropriate
Motivating and coaches staff to include new-hire training, problem solving, and special projects
Assisting manager with performance activities to include monitoring, coaching, educating, and providing feedback to team
Ensuring UM Physicians are provided the relevant information needed to accurately review a referral
Fostering the relationship between the Pre- Authorization team and the Medical Director and Physician Reviewers
Tracking cost savings from activities over time to evaluate success of programs
Maintaining or removes programs based on organization and department goals
Developing reports for leadership as required