- Provides overall direction, design, development implementation and monitoring of utilization programs to meet the Service Areas or Medical Centers utilization goals while maintaining customer satisfaction.
- Acts as a resource to the medical staff, administrative staff, divisional, SCPMG, TPMG and external regulatory agencies in all issues relating to utilization management within the Service Area or Medical Center.
- Oversees outside medical services based on Health Plan benefit guidelines and medical necessity.
- Analyzes and reports significant utilization trends, patterns, and impact to appropriate departmental and medical staff committees.
- May direct the operations of outside referrals/transportation services.
- May serve as contract liaison for the Service Area or Medical Center on issues pertaining to new or existing contracts with outside vendors.
- Develops, monitors and controls departments budgets.
- Assures compliance with Federal, State, TJC, NCQA, other regulatory agencies and internal standards and requirements.
- Hires, coaches, trains and disciplines staff to ensure smooth operations in utilization management.
- Also facilitates educational training for medical staff on issues related to utilization management.
-
Utilization Manager Ii
2 weeks ago
Sharp Healthcare San Diego, United States[Certified Case Manager (CCM) - Commission for Case Manager Certification; Accredited Case Manager (ACM) - American Case Management Association (ACMA); Bachelor's Degree in Nursing; California Registered Nurse (RN) - CA Board of Registered Nursing; Bachelor's Degree · **Hours**: ...
-
Lvn, Utilization Management
1 week ago
Optum San Diego, United StatesFor those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start **Caring. Connecting. Growing together.** · Optum's Pacific West region is redefining ...
-
Associate Project Manager, Electric Utility
3 weeks ago
4Liberty San Diego, United States**Location**: · **General Summary**: · Seeking a high-energy, detail oriented, safety focused Project Coordinator to be part of an established professional services team providing program management services to investor-owned gas and electric utilities. We provide clients with ov ...
-
Manager, Utility Scale Development West Region
3 weeks ago
RWE Clean Energy San Diego, United States**Manager, Utility Scale Development West Region**: · - **Location(s)**: · - San Diego, CA, US, 92101 · - San Francisco, CA, US, n/a · **RWE Clean Energy, LLC** · **Functional area**:Project Development · **Remuneration**:Exempt · The **Manager, Utility-Scale Developer **at RWE C ...
-
Case Manager Utilization Rn, 40/hr Night
3 weeks ago
Kaiser Permanente San Diego, United States**Sign On Bonus for Eligible External Hires** · **Job Summary**: · Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not m ...
-
Kaiser Permanente San Diego, United States**Job Summary**: · Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospital ...
-
Utilities and Energy Management
1 week ago
U.S. Marine Corps Marine Corps Air Station Miramar, United States**Duties**: · - You will plan and schedules work assignments on a long-range basis, preparing budget estimates and allocating resources within the branch. · - You will determine program goals and plans, independently or in conjunction with higher management. · - You will establis ...
-
LVN, Utilization Management
2 weeks ago
UnitedHealth Group San Diego, CA, United StatesFor those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start **Caring. Connecting. Growing together.** · Optum's Pacific West region is redefining ...
-
Director Utilization Management
3 weeks ago
Kaiser Permanente San Diego, United States: Job Summary: · Develops, manages and directs the Utilization Management programs in a Service Area or a Medical Center. Develops and manages programs that emphasize appropriate admissions as well as concurrent and retrospective review of care. May also be responsible for other ...
-
Central Utility Plant Manager
3 weeks ago
Power Industry Support, LLC San Diego, United StatesPower Industry Support, LLC is actively recruiting a · Central Utility Plant Manager · for the Rady Childrens Hospital located in San Diego, CA. The facility has a 5MW Gas Turbine with a Heat Recovery Boiler, Auxiliary Steam Boilers, Electric and Absorption Chillers, Automation ...
-
Utilization Review-Case Management
2 weeks ago
Aurora San Diego San Diego, United States Full timeJob Description · Job DescriptionWork as member of multi-disciplinary treatment team reviewing patient care and treatment options for both inpatient and outpatient services. Proactively monitor and optimize reimbursement for external reviewers/third party payers. · *Pay Range: $3 ...
-
Utilization Review-Case Management
3 weeks ago
Aurora San Diego Hospital San Diego, United States Full timeWork as member of multi-disciplinary treatment team reviewing patient care and treatment options for both inpatient and outpatient services. Proactively monitor and optimize reimbursement for external reviewers/third party payers.Pay Range: $32/hr. to $60/hr · Responsibilities:Ad ...
-
Central Utility Plant Manager
3 weeks ago
DTE Energy San Diego, United StatesDTE is one of the nation's largest diversified energy companies. Our electric and gas companies have fueled our customer's homes and Michigan's progress for more than a century.And as Michigan's largest source of renewable energy, we're creating a cleaner, healthier environment t ...
-
Central Utility Plant Manager
3 weeks ago
DTE Energy San Diego, United StatesDTE is one of the nation's largest diversified energy companies. Our electric and gas companies have fueled our customer's homes and Michigan's progress for more than a century.And as Michigan's largest source of renewable energy, we're creating a cleaner, healthier environment t ...
-
Case Manager Utilization Rn, 40/hr Day
1 week ago
Kaiser Permanente San Marcos, United States**Sign On Bonus for Eligible External Hires** · **Job Summary**: · Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not m ...
-
Case Manager Utilization RN, 40/hr Night
2 weeks ago
Kaiser Permanente San Diego, United States: Sign On Bonus for Eligible External HiresJob Summary:Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medi ...
-
Case Manager Utilization RN, 40/hr Night
1 week ago
Kaiser Permanente San Diego, United StatesSign On Bonus for Eligible External Hires · Job Summary: · Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the ...
-
Case Manager Continuing Care Coord RN-PD
2 weeks ago
Kaiser San Diego, United States Full timeCoordinates with physicians, staff, and non-Kaiser providers/facilities regarding patient care/ population based management for patients in specifically defined geriatric or other specifically defined patient populations in order to plan and implement a comprehensive, multi-disci ...
-
Rn Case Manager
3 weeks ago
Rady Children's Hospital-San Diego San Diego, United States**JOB SUMMARY**: · Case Managers function as liaisons between patients, their families, and internal and external health care personnel to ensure appropriate, efficient, and timely health care service. Their focus includes providing clinical documentation to third party payers to ...
-
Rn Case Manager I
2 weeks ago
Sharp Healthcare San Diego, United States[Master's Degree; Bachelor's Degree in Nursing; Certified Case Manager (CCM) - Commission for Case Manager Certification; Accredited Case Manager (ACM) - American Case Management Association (ACMA); California Registered Nurse (RN) - CA Board of Registered Nursing · **Hours**: · ...
Director Utilization Management - San Diego, United States - Kaiser Permanente
Description
: Job Summary:Develops, manages and directs the Utilization Management programs in a Service Area or a Medical Center. Develops and manages programs that emphasize appropriate admissions as well as concurrent and retrospective review of care. May also be responsible for other integrated functions such as Discharge Planning, Case Management program, Outside Utilization Review program, Transportation coordination and Extended Care Coordination to promote a centralized, coordinated, interdisciplinary process in the continuum of care.
Essential Responsibilities:
Basic Qualifications:
Experience
·Minimum three (3) years of experience in directing utilization management and discharge planning in an acute care setting.
Education
·BSN or bachelor's degree in healthcare related field such as management, health services administration.
License, Certification, Registration
·Registered Nurse License (California)
Additional Requirements:
·Demonstrated knowledge of operations and healthcare management; TJC, Title XXII, Medicare, Medi-Cal and other local, state and federal regulations.
·Knowledge of managed care operations.
·Demonstrated interpersonal, negotiation, and leadership skills.
·Effective oral and written communication skills.
·Must be able to work in a Labor/Management Partnership environment.
Preferred Qualifications:
·Master's degree in a related field such as nursing, business or health services administration preferred.