The Lead Utilization Management Case Manager will be responsible for the day to day activities of the utilization management department. The lead UM Case Manager will be responsible for the oversight of UM clinical and non-clinical staff day to day activities. The lead UM Case Manager will assist in reviewing the UM policies and procedures with the UM Manager or UM Director and be able to make suggestions for improvement and efficiencies within the UM department. The lead UM Case Manager will continue to review authorizations as assigned. The lead UM Case Manager oversees the authorization process to ensure that the member receives benefits in accordance with their coverage in a quality and cost effective manner. The goals of this position is to collaborate with the Lead UM Coordinator and assist the UM Manager and UM Director with day to day operations while reviewing authorizations that are medically necessary to appropriate physicians/vendors in a timely manner.
Oversight of the UM clinical and non-clinical staff day to day activities.
Monitor UM department queue reports for all IPAs and address potential out of compliance referral with the assigned team and the UM Manager.
Monitor urgent referrals queues and ensure department required TAT.
Monitor clinical and non-clinical staff productivity and address potential deficiencies with UM Manager and UM director.
Responsible for training of new UM staff including UM coordinators and UM Case Managers.
Responsible for communicating the UM staff daily schedule to other departments.
Responsible for adjusting daily assignments of the UM clinical and non-clinical staff to meet the department needs.
Acts as a liaison between UM and internal departments and/or external providers.
Point person and provide support to customer service and provider relations for all referral related questions.
Assist with updating the UM department policies and procedures.
Review authorization requests for medical appropriateness and correct contracted vendor.
Liaison with designated Medical Director for complex authorization requests.
Maintains knowledge of current contractual arrangement with the Health Plans and vendors.
Functions as clinical resource for benefit interpretation. Researches complicated cases.
Screens for CCS diagnosis and refers appropriately.
Screens all tertiary referrals and refers appropriately.
Oversees assigned UM Coordinators to ensure accurate and timely processing of the authorizations.
Responsible for presenting the clinical criteria to support denial of services.
Attends monthly UM Committee meeting for related groups and assists in the preparation of the agenda, minutes, and packet.
Identify any patterns of over/under utilization and refer to appropriate source.
Refer appropriate cases to the Outreach Department.
Perform related duties or fill in for others in the department as assigned by UM Manager and UM Director.
The Nurse is responsible for collaborating with his/her UM coordinator or designee and ensure the assignment is completed in a timely manner and referrals are processed in accordance with UM Department turn-around-time standards.
Review daily and approve services on the UM Nurse Business Rules and approval level set forth by the UM Department.
Prepare cases for Medical Director to review as needed.
Upon denial of a request by the Medical Director, draft the denial language and send the file to the Denial Team in accordance with the department turn-around-time standards.
Pended Requests – Indicate what supporting documents are needed and prepare the file to send to the Denial Team.
Correspond with the requesting provider/vendor as needed to obtain additional clinical information for referral processing.
EIOD – Ensure the oral notification is completed and documented in the system as required by CMS.
Foster positive interaction and relationships with all internal departments as well as cultivating positive working relationships with external contacts.
Prevent and avoid harassment and discrimination. Respond promptly to any complaints in accordance with policies in the Employee Handbook.
Maintain attendance and professionalism at all times in accordance with Tenet’s policy.
Perform other assigned duties / special projects on an as-needed basis as directed by the UM Manager and UM Director
California License Required, RN or LVN
Minimum 3 years utilization review, case management or discharge planning experience in an IPA, Medical Group, Hospital or Health Plan environment.
Acute hospital experience preferred
Knowledge of clinical guidelines such as CMS NCD/LCD, Apollo, MCG, or Interqual Guidelines
Knowledge of NCQA, health plan and CMS guidelines.
Previous experience as lead or supervisor preferred.
Computer skills required.
JOB: Case Management/Home Health
PRIMARY LOCATION: Cypress, California
FACILITY: Coast Healthcare
JOB TYPE: Full-Time
SHIFT TYPE: Days
Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.