Supervisor of Utilization Management

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.
• 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.

Qualifications

• Education and Experience: Associate or Bachelor’s degree in nursing. RN with 3-5 years’ experience to include staff supervision; one (1) year managed care (case management) experience; or equivalent combination of education and experience.
• Special Skills, Licenses and Certifications: Current California RN license. RN Supervisor will be supervising both RN and LVN staff. Case Management certification preferred. 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.