Manages the day-to-day operations of the Utilization Management Program in the Service Area or a Medical Center. Ensures cost effective & quality patient care by appropriate utilization of resources. Provides direction to staff which may include Outside Utilization, Extended Care, Bed Placement, Discharge Planning, Transportation, & others as assigned.
Essential Functions:
- Assists in developing & maintaining policies & procedures for the Service Area or Medical Center related to Utilization Management
- Collaborates with the multi-disciplinary teams to plan & coordinate care across the continuum
- Coordinates & manages members' care with non-KFH hospital facilities & providers
- Identifies risk management & quality of care issues across the continuum
- Surfaces issues & any suggestions to the appropriate multi-disciplinary team members
- Manages transportation program to ensure appropriate utilization of resources which meet Health Plan guidelines & patient needs
- Assures compliance with Federal, State, JCAHO, NCQA, other regulatory agencies, & internal standards & requirements
- Provides direction to staff regarding utilization review, care coordination, discharge planning, & other services across the continuum of care
- Assists in conducting statistical studies in utilization trends, patterns, & outcomes
- Hires, trains coaches, disciplines professional & clerical support staff
Qualifications:
Basic Qualifications:
- At least three (3) - five (5) years of experience in utilization management and discharge planning in an acute care setting which also includes previous supervisory or management experience
- BSN or BA or BS degree in healthcare related field such as management, health services administration
- Current California RN license
- Demonstrated knowledge of operations and healthcare management; JCAHO, Title XXII, Medicare, MediCal, and other local, state and federal regulations
- Knowledge of managed care operations
- Demonstrated interpersonal, negotiation, and management skills
- Good oral and written communication skills
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.