SUPV - Medical Management - Full Time

UHS•Riverside, CA

About The Position

Come and join the RMC Family! We have been in the community since 1935. Our mission is to provide comprehensive multi-specialty medical services in the greater Riverside region. Your passion, inspiration, and talents are invaluable to us and our mission to serve others. Our facility can provide a place for you to thrive and continue your professional development. Quality Healthcare is our passion, improving lives is our reward. We are working to change lives and transform the delivery of healthcare. Riverside Medical Clinic is the best place to work, practice medicine, and receive care. SUMMARY: Assists and supports the Director/Manager of Medical Management. Provides and ensures staff is screening the accuracy of eligibility, benefits, clinical guidelines (as applicable and appropriate) based on department policies and procedures and health plan compliance. Ensures that referrals are adjudicated according to the referral process as per health plan and regulatory standards. Assists in preparing required documentation and reports for Health Plan audits and appeals. Assists Director/Manager with onboarding and ongoing staff training on Benefits/Eligibility/Coverage Maintenance Responsibilities according to UM processes and policies and procedures. Provides other staff training, in-services, and disciplinary action as needed and as directed by Director/Manager of Medical Management. Performs regular internal audits of staff processes according to policies and procedures of the department to ensure compliance with payors delegation agreements.

Requirements

High school diploma or general education degree (GED) required.
Requires an associate degree in nursing RN, or LVN.
Three (3) years utilization and case management experience working in a managed care setting working with insurance payors, or a combination of some college plus five (5) or more years HMO and insurance experience required in the area of utilization and case management.
Two (2) years supervisory experience required.
Must possess good written and verbal communication skills, ability to work in a fast-paced busy environment, meet stringent deadlines, and multi-task, have excellent computer skills with Excel and Word.
Medical terminology needed, and have a good understanding of EMTALA, NCQA, DMHC, CMS regulatory requirements with Medicare Advantage.
Current, active, non-restricted California Registered Nursing License or LVN license.

Responsibilities

Responsible for the collection of accurate data from utilization of services within the Utilization management Department. Prepare useful utilization statistics from this data.
Communicates with other departments, health plans, providers, and members to resolve benefit and eligibility issues. Resolve escalated issues from external and internal customers.
Establishes work procedures and evaluates processes for improvement. Monitor staff productivity and turnaround time on a daily, weekly, and monthly basis to ensure accuracy, productivity and attaining department goals.
Prepare and authorize work schedules for UM Coordinators and Nurses, maintain attendance records and update payroll systems.
Develop and implement monthly utilization statistics, as necessary, for use in Utilization Management Department and Utilization Management Committee.
Verify patient benefits and eligibility prior to authorizing services or supplies as needed.
Communicate system malfunctions to appropriate department and required benefit file updates, as necessary, to ensure system accuracy.
Update authorizations in the system to ensure timely turnaround and compliance with health plan requirements.
Responsible for interviewing, hiring, training, coaching, counseling and termination of employees.
Provide day-to-day supervision of assigned UM staff and participate in staff training.
Monitor UM staff for consistent application of UM criteria applicable to level and type of UM decisions made to include but not limited to adherence to all UM policies and procedures.
Monitor documentation for adequacy of information required to effectuate/adjudicate a referral.
Monitor staff adherence to all UM policies and procedures and compliance with regulatory requirements by health plan payors to meet the Company’s contractual delegation obligations.
Availability to UM staff on site or by telephone on a day-to-day basis during regular working hours, on the weekends for weekend on-call staff, and or as needed by the department.
Provide supervisory oversight to the UM department and assist the Director/Manager in all areas of the UM department as directed by the Director/Manager.
Conduct introductory assessment and annual performance evaluations as required and provides input and recommendations/goals.
Ensure all documentation pertaining to employee issues, training records, and any related company policies and procedures are compliant with health plans delegation requirements, governmental and company protocols.
Assists Director/Manager in conducting monthly staff meetings and or ad hoc meetings.
Assist Director/Manager of Medical Management in determining staffing needs.