Utilization Review Supervisor - San Jose, United States - County of Santa Clara CA

Description

Salary : $194, $248,456.00 Annually

Location : San Jose Metropolitan Area, CA

Job Type: Full-Time

Job Number: 24-S1M-A

Department: Valley Health Plan

Opening Date: 06/06/2024

Closing Date: 6/21/2024 11:59 PM Pacific

Bargaining Unit: 92

Description

Under direction, to organize, direct, and supervise the Utilization Review functions as required by Federal and State regulations and the Valley Health Plan (VHP) Utilization Review department.

The Utilization Review Supervisor - VHP position provides effective leadership, develops and implements solutions to address efficiency and compliance issues, and optimizes workflow and operations within the Utilization Management unit. The ideal candidate will have strong knowledge of Federal and State health care laws and regulations common to the operation of hospitals in California as well as innovative thinking, strong analytical skills, root cause analysis, and application of evidence-based clinical guidelines. In addition, this position will be expected to work collaboratively with VHP's physician leadership and apply critical thinking to make decisions on covered medically necessary services.

Typical Tasks

The following is a descriptive list of the range of duties performed by employees in this classification and is not intended to reflect all duties performed by every incumbent in this classification:

• Directs, evaluates, and develops systems and procedures to meet the goals and objectives of the Utilization Review department for VHP;
• Evaluates the compliance of the Utilization Review functions in terms of state-mandated standards and regulations, and offers solutions and efficiencies to improve compliance with required regulations;
• Supervises, directs, trains, and evaluates utilization review staff, which is comprised of clinical and non-clinical team members;
• Prepares work schedules and makes assignments;
• Attends meetings as required;
• Evaluates Utilization Review policies and procedures and makes recommendations regarding such;
• Prepares and submits reports as required;
• Acts as a technical resource for VHP staff as it relates to Utilization Review;
• May be assigned as a Disaster Service Worker, as required;
• other related duties, as required.

Employment Standards

Sufficient education, training, and experience to demonstrate the possession and direct application of the following knowledge and abilities:

Experience Note:The required knowledge and abilities are attained through possession of an Associate's Degree in Nursing, Health Care Administration, or a related field,

and

Five (5) years of nursing or utilization management, case management, or equivalent experience in a managed care/HMO environment or patient care setting, and one (1) year of lead and/or supervisory experience. The lead and/or supervisory experience may be inclusive of the nursing or utilization management, case management, or equivalent experience.

OR

Possession of a Bachelor's Degree in Nursing, Health Care Administration, or a related field,

and

Three (3) years of nursing or utilization management, case management, or equivalent experience in a managed care/HMO environment or patient care setting, and one (1) year of lead and/or supervisory experience. The lead and/or supervisory experience may be inclusive of the nursing or utilization management, case management, or equivalent experience.

Possession of a Master's Degree in Nursing, Health Care Administration, or a related field may substitute for one (1) year of the required patient care or managed care/HMO experience.

Special Requirements

• Possess and maintain a valid California Registered Nurse License.
• Possession of a Utilization or Case Management certification is highly desired.
• Ability to travel to alternate locations in the course of work. If driving, possession of a valid California driver's license prior to appointment and the ability to qualify for and maintain a County driver authorization.

Knowledge of:

• Hospital organization, operations, and procedures;
• Principles of supervision and program management;
• Federal and State health care laws and regulations common to the operation of hospitals in California;
• Regulations of intermediary agencies pertaining to hospital stay coverage (e.g., Medicare/Medi-Cal);
• Medical terminology and related levels of care and treatment;
• Principles and applications of a hospital data processing system as it relates to Utilization Review;
• Policy and procedure development;
• Role of the public teaching hospital;
• Evaluation and assessment techniques.

Ability to:

• Analyze, develop, and implement effective reporting systems and procedures;
• Analyze, interpret, apply, and implement Federal and State rules and regulations;
• Collect and record data;
• Act as a technical resource to physicians and Utilization Review staff;
• Supervise, plan, and assign workload of Utilization Review staff;
• Evaluate data and statistics;
• Work independently to set priorities and make effective decisions;
• Communicate effectively in English, both orally and in writing;
• Establish and maintain effective working relationships with those contacted in the course of work, at all levels, including colleagues, the public, and other agencies.

The County offers comprehensive first-class medical, dental, and vision benefits plans for County employees and their dependents, including plans with no deductibles, no co-pays, no co-insurance, and no prescription drug co-pays. Learn more

The County also offers generous paid time off with significant vacation, sick time, and 13 paid County holidays annually Details are included in the with the bargaining unit applicable to the job classification.

In addition to the amazing perks above, the County also offers the additional benefits below.

Retirement Benefits
The County offers robust retirement plans including a (similar to the private sector's 401(k) plan) and the In addition to lifetime retirement income available through the CalPERS pension plan, the 457(b) Deferred Compensation plan provides a great way to save for retirement and supplement the defined benefit pension available to employees. These plans help our employees build a plan for their future and contribute to their family's long-term financial well-being.

Health Flexible Spending Account
The empowers employees to manage healthcare expenses efficiently with tax-free contributions (up to $3,200 for the 2024 calendar year). Secure tax-free solutions for your healthcare expenses and enjoy the flexibility to manage your healthcare finances effectively with the HFSA.

Dependent Care Assistance Program (DCAP)
The enables employees to utilize tax-free funds for dependent care services, facilitating a convenient and cost-effective approach for managing your dependent care expenses. The County also offers the , an employer-funded DCAP, for employees with annual income under $120,000.

Life and AD&D
The County offers life and disability benefits including , Insurance, These benefits ensure financial security and income support when you and your family need it most.

Employee Assistance Program (EAP)
The County prioritizes employee mental health and well-being and offers a top-tier through Concern providing confidential counseling sessions covering stress, anxiety, relationships, grief, as well as financial/legal services, personal coaching, child and elder care referrals, and comprehensive crisis support.

Employee Wellness
The offers free wellness programing, fitness classes and resources; including Elevate My Wellness an all-in-one platform designed to elevate your well-being journey.

Education Reimbursement
A generous program is available, including Education Reimbursement for employees seeking additional training and professional development.

NOTE: Benefit and Retirement information may vary from bargaining unit to bargaining unit. Due to changes in State Law, current pension provisions described in the union contracts are not automatically applied. Specific pension benefits for new hires who start on or after January 1, 2013 may be different than indicated in the union contracts.

Click here to access all Memoranda of Understanding and most recent Summary of Changes.

01

Please answer the following questions. Completion of the following supplemental questions is REQUIRED and is an integral part of the evaluation process. Initially, it will be used to determine minimum qualifications. For those applicants meeting the employment standards, this information will be critical in the subsequent competitive assessment to identify those candidates to be invited to continue in the examination process. Your responses to the questions may also be reviewed and scored in a Competitive Rating evaluation process based on pre-determined rating criteria. Your answers should be as complete as possible, as no additional information will be accepted from applicants once the Competitive Rating evaluation has begun. A response of "see resume" or "see application" will deem your application incomplete.
Include a detailed description of your work experience in the following format for EACH employer referenced, in each answer:
a) Employer name(s)
b) Job title(s)
c) Start/end dates of employment
d) Total hours worked per week
e) Description of task(s) performed

Do you understand the requirement to provide complete answers in order to determine relevant experience for each area in question?

• Yes
• No

02

What is your Santa Clara County Employee ID number? If you do not have a Santa Clara County Employee ID number, type n/a.

03

Did you separate from the County through the 2020 Voluntary Separation Incentive Program (VSIP)?

• Yes
• No

04

What is the highest level of education you have completed?

• High School or GED equivalent
• College (1 to 29 semester units / 1 to 44 quarter units)
• College (30 to 59 semester units / 45 to 89 quarter units)
• College (60 to 89 semester units / 90 to 134 quarter units)
• College (90 to 119 semester units / 135 to 179 quarter units)
• College (120 or more semester units / 180 or more quarter units)
• Associate's Degree
• Bachelor's Degree
• Master's Degree
• Doctoral Degree

05

Please select which nursing or public administration fields you have a degree in.

• Nursing
• Health Care Administration
• Public Health
• Other related field
• Non-related field

06

Do you have an active California Registered Nurse License without restrictions?

Please be sure to include all requested RN License information under "Certificates and Licenses" in your application above.

• Yes
• No

07

How many years of nursing, managed/complex care, case management, or utilization review experience do you have?

• None to less than one year
• One year or more but less than three
• Three years or more but less than five
• Five years or more

08

Please describe your experience with Utilization Management and Case Management departments in regards to health plans. Include staff supervised, functions performed, and any metrics used to track staff performance. If none, enter "N/A"

09

Please describe your experience using Utilization Management and Case Management performance indicators. Specifically focus on performance indicators used for reporting in health plans and reporting to the Department of Managed Health Care. If none, enter "N/A"

10

Please describe your experience in resolving, tracking and/or trending Utilization Management authorization concerns from health plan members and providers. If none, enter "N/A"

11

Please describe your experience in resolving, tracking and/or trending concerns from health plan members and provider disputes from providers. If none, enter "N/A"

12

Please describe your experience with Utilization Management data collection and analysis, specifically with bed days, admits per thousand, per member per month utilization metrics, and utilization within and outside of the network. If you have none, enter "N/A"

13

Please describe your experience working with regulators such as the Department of Managed Health Care and the Department of Health Care Services, and responding to corrective action plan from these regulators. If you have none, enter "N/A"

14

Please describe your experience with manipulating large data sets, stratifying members into care levels, developing interventions for cohorts and developing measurable outcome measures. If none, enter "N/A"

15

Please describe your experience with manipulating large data sets, stratifying provider disputes or member appeals or grievances and designing interventions to mitigate unfavorable trends and developing measurable outcome measures. If none, enter "N/A"

16

Please describe your experience with care management (case or utilization management) system design, configurations and testing. If none, enter "N/A"

17

Please describe you experience with stating new programs and/or their development. If none, enter "N/A"

18

Please describe your experience with drafting, analyzing, and writing requirements for care management systems. If none, enter "N/A"

19

Please describe your experience with training staff. Be sure to include number trained and type of training as well as any other relevant information. If you have none, enter "N/A"

20

Please describe your level of computer literacy and skills in software applications (such as Visio, Excel, PowerPoint, etc.). If you have none, enter "N/A"

21

How did you find out about this job?

• Contacted by County Recruiter
• Contacted by a Recruitment Firm
• County Employee Referral
• County of Santa Clara Career Website
• County of Santa Clara Job Interests Email Notification
• Facebook
• Instagram
• LinkedIn
• Indeed
• Virtual Job Fair
• In Person Job Fair
• In-Person Networking Professional Event
• Virtual Networking Event
• Community Event
• Glassdoor
• Professional Association
• Search Engine (Google, Bing, online search, etc.)
• Hospital Website: SCVMC, O'Connor Hospital, St. Louise Regional Hospital Website
• Handshake
• Student Career Center
• County Text Message
• Other (Specify in the next question)

22

If you selected an event/fair or other in the question above, please specify. If not, type n/a.

Required Question