Provides executive level leadership, strategic direction and recommendations regarding a comprehensive Regional Utilization/Resource Management plan.
This position will provide regional leadership and oversight of the utilization/resource management work throughout SCAL. This position is responsible for the development, planning, management and integration of Southern California's utilization strategies across the full continuum of care to ensure that all SCAL members/patients efficiently receive the care that they need in the right setting at the right time.
Provides oversight and direction to the Complex Case Management and SNP programs as well as the RUC (Regional UM Compliance) team other programs.
Interfaces with regulatory and government agencies including DMHC, NCQA, JCAHO, to effect change in collaboration with the Southern California Permanente Medical Group, Program Offices, and Northern California leadership. It enhances the ability of the medical centers to achieve high quality patient care outcomes across the full continuum but with an emphasis on Hospital utilization.
Ensures systems are in place to enhance Health Plan oversight of these activities through active participation and leadership.
Should be a recognized content expert on utilization/resource management including creating and executing performance measurement best practices and strategies.
Essential Functions:
- Provide executive level leadership, strategic direction and recommendations regarding a comprehensive Regional UM/Resource Management plan.
- Provides expertise and operational leadership and consultation to SCAL executive leaders, SCPMG, and the fourteen SCAL medical centers regarding Utilization/resource management.
- In conjunction with regional and local leaders, develops the structures, processes, metrics and accountabilities across the full continuum of care to ensure that patients receive the right care that they need in the right setting at the right time.
- Partners with SCPMG Physician leaders regarding the successful implementation of the IQM model throughout all SCAL.
Strategic Planning:
- In conjunction with regional and medical center leadership develops the strategic plan for appropriate use of services across the continuum of care.
- Anticipates and plans for future changes in Utilization/Resource Management practices and regulatory requirements.
Leadership & Direction:
- Identifies and institutes performance improvement efforts based on evidence based research, practices and patient outcomes.
- Facilitates the rapid transfer of best practices among the SCAL medical centers.
- Serves as a knowledgeable content expert regarding utilization management regulations, practices, and compliance.
Finance:
- Understands the finances of various care settings and contributes ideas and plans for efficient utilization of resources appropriately.
Program Development:
- Directs program planning and development from a regional level to benefit the local medical centers.
- Provides oversight to ensure that policies, procedures and practices comply with administrative, legal and regulatory requirements
Qualifications:
Basic Qualifications:
- Master's degree in Nursing, Health Services, Business Administration or Public Health/Administration. Bachelor's degree in one of the above.
- Substantial experience (10+ years) progressive operational experience in clinical and leadership roles in a mulit-faceted health care system and multi-provider settings. Recent (within last 6 years) experience at a medical center.
- Substantial relevant and progressive experience (8+ years) in utilization/resource management.
- Demonstrated knowledge of the intricacies of hospital/HMO/medical offices operations and practices.
- Demonstrated knowledge of SNP, CCM and LTC.
- Thorough knowledge of health care policy trends, resource management and regulatory and licensing requirements.
Preferred Qualifications:
- California RN license strongly preferred.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.