Supervisor of Utilization Management

Partnership HealthPlan of California • Fairfield, CA

4d • $136,297 - $177,186 • Onsite

About The Position

To provide daily supervision of utilization management staff. Provide departmental leadership, support, resources and direction to staff. Assists in developing and maintaining a cohesive team with a high level of productivity, accuracy and quality to achieve departmental goals and objectives.

Requirements

• Associate or Bachelor’s degree in nursing.
• RN with 3-5 years’experience to include staff supervision
• one (1) year managed care (casemanagement) experience
• Current California RN license.
• RN Supervisor will be supervising both RN and LVN staff.
• Strong knowledge of nursing requirements in a clinical setting.
• Knowledge of utilization management programs as related to use of pre-set criteria and protocols.
• Familiarity with business practices and protocols with ability to access data and information using automated systems.
• Ability to work within an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities and meeting deadlines.
• Strong organizational skills required.
• Effective telephone and computer data entry skills required.
• Valid California Driver's License and proof of current automobile insurance compliant with Partnership's policies are required to operate a vehicle and travel for company business.
• Ability to use a computer keyboard.
• Ability to prioritize workload and initiate action to acquire needed information from professionals by phone.
• Ability to function effectively with frequent interruptions and direction from multiple team members.
• More than 50% of work time is spent in front of a computer monitor.
• Must be able to lift, weigh up to 10 lbs.
• Provide the highest possible level of service to clients
• Promote teamwork and cooperative effort among employees
• Maintain safe practices
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

Nice To Haves

• General knowledge of managed care with emphasis in casemanagement preferred.
• Case Management certification preferred.
• Knowledge of DHCS, Medi-Cal, CMS, medically necessary criteria, CalAIM and/or NCQA regulations.
• Computer literacy and proficiency.
• Excellent written and verbal communication skills in English.
• Demonstrated experience and ability to build effective working relationships and to represent the department effectively in order to accomplish goals.
• Ability to manage multiple concurrent projects and maintain a work pace appropriate to the workload.
• Ability to assist individuals in recognizing and solving problems.
• Ability to supervise, train, motivate, provide guidance to staff.
• Some travel required (up to 25%) including occasional overnight.

Responsibilities

• Provides daily leadership, direction, resources, training, evaluation, coverage and program support to assigned staff.
• Performs supervisory functions such as timecard management, staff scheduling to meet business requirements and directing work activities.
• Provides performance feedback to utilization management staff and conducting annual reviews.
• Participates in the interviewing, hiring and on-boarding processes of new staff.
• Maintains active participation with inbound and outbound provider reporting and other related duties, adjusting assignments as necessary to meet business needs and/or regulations.
• Documents and maintains patient-specific records in the Partnership computer system, in databases and files as applicable.
• Participates in committees, workgroups and/or multidisciplinary teams to support Partnership’s strategic plan, organizational goals, and/or business needs.
• Facilitates meetings with Partnership community provider partners as a part of utilization management process.
• Develops and maintains positive working relationships with all business partners to ensure optimum member care and provider satisfaction.
• Reviews department desktops, policies and procedures, recommends changes for more efficient operations, and communicates changes and updates to staff when appropriate.
• Researches and responds to provider issues or barriers ensuring successful outcomes and superb customer service.
• Audits medical records as appropriate for accuracy, workflow evaluation, staff feedback and process improvement activities.
• This position, in addition to his or her own case load, may be assigned cases in the area of oversight as deemed necessary to provide coverage.
• Evaluates appropriateness of care through interpretation of benefits as outlined in Title 22, Medi-Cal Provider Manual, DMHC CMS regulatory requirements, Partnership Policies and Procedures, and medical necessity criteria for each product line.
• Researches and responds to provider issues or barriers, ensuring successful outcomes and superb customer service.
• Participates in special projects and assignments as required.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree