- Manages the administrative and operational functions of the regional utilization management department.
- Responsible for the planning and decision-making related to utilization review.
- Develops and implements departmental policies and procedures.
- Develops, implements, and maintains utilization management programs to facilitate the use of appropriate medical resources by health plan members/patients.
- Identifies and monitors services with potential for undesirable variation to ensure accurate and consistent application of benefits and clinical guidelines or criteria. Develops and reviews medical necessity criteria and utilization management practices including a formal process of monitoring and evaluating the necessity, appropriateness, efficiency, effectiveness, and safety of medical services to achieve favorable healthcare outcomes.
- Reviews analyses of activities, costs, operations and forecast data to determine progress toward utilization management goals and objectives.
- Compiles and reviews multiple reports for statistical and financial tracking to identify utilization trends and make recommendations to management and to ensure inter-rater reliability of staff performance.
- Ensures compliance with national and state regulatory/accreditation requirements related to utilization management by partnering with other departments and facilitating workgroups in maintaining survey readiness to ensure that all annual requirements are met.
- Engages in monthly/quarterly/annual/triennial internal and external utilization management audits and surveys and delegation oversight audits.
- Manages and oversees the utilization review management training and education program for Utilization Review leaders and staff across the region.
- Ensures post-course evaluation tools and other materials are developed.
- Manages training and education schedules.
- Manages case managers including hiring, training, performance evaluations and terminations.
- Ensures tools and technology are created and improved to perform activities and ensure timely and appropriate documentation for accurate data capture and reporting.
- Facilitates on-going communication and manages relationships among utilization management staff, internal providers care management peers and leaders, and external/contracted providers.
- Manages performance and issues with internal and external representatives regarding Union Issues, as necessary.
- Minimum three (3) years of experience in directing utilization management and discharge planning in an acute care setting.
- Bachelors degree in related field OR four (4) years of experience in a directly related field.
- High School Diploma or General Education Development (GED) required
- N/A
- Thorough knowledge of utilization management and clinical practice.
- Familiarity with Medicare and Medicaid managed care practices and policies, CHIP and SCHIP.
- Knowledge of regulatory/accreditation requirements (NCQA, DMHC, DHCS, CMS, Medi-Cal Plan Partners, Special Needs Plan (SNP)).
- Recent clinical experience in a hospital setting preferred.
- Bachelors degree in nursing preferred.
- Case Management Certification preferred.
- CO RN license preferred.
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Regional Utilization Management Director - Aurora, United States - Kaiser Permanente
Description
: Salary Range: $65.38/hour - $84.56/hour$ $71.20
Job Summary:
Manages the overall, regionwide utilization management function ensuring the accurate and timely prior authorization of designated healthcare services. Oversees the concurrent, discharge planning and retrospective review activities for the Colorado region. Manages utilization review staff.
Essential Responsibilities:
Experience
Scheduled Weekly Hours: 40
Shift: Day
Workdays: Mon, Tue, Wed, Thu, Fri
Working Hours Start: 08:00 AM
Working Hours End: 05:00 PM
Job Schedule: Full-time
Job Type: Standard
Worker Location: Remote
Employee Status: Regular
Employee Group/Union Affiliation: NUE-CO-02|NUE|Non Union Employee
Job Level: Director/Senior Director
Department: Waterpark I - Med Adm-Cont Care Extrnl Svcs
Pay Range: $ $175890 / year The ranges posted above reflect the location in the job posting. The salary range may vary if you reside in a different location or state than the location posted.
Travel: No
Remote: Work location is the remote workplace (from home) within KP authorized states. Worker location must align with Kaiser Permanente's Authorized States policy. At Kaiser Permanente, equity, inclusion and diversity are inextricably linked to our mission, and we aim to make it a part of everything we do. We know that having a diverse and inclusive workforce makes Kaiser Permanente a better place to receive health care, a more supportive partner in our communities we serve, and a more fulfilling place to work. Working at Kaiser Permanente means that you agree to and abide by our commitment to equity and our expectation that we all work together to create an inclusive work environment focused on a sense of belonging and wellbeing.
Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status. Submit Interest
