OVERVIEW OF POSITION:
Responsible for the oversight, management and optimization of all quality improvement and utilization management activities. Safeguards that all Utilization Management (UM) functions are in compliance with regulatory and health plan standards including policies and procedures across health plans, NCQA and other regulatory agencies plan standards. Manages staff directly responsible for the day-to-day operations of the regional denial unit. Monitors UM processes and functions to ensure proper use clinically based criteria and health plan specific guidelines, compliance with turn-around time requirements. Ensures correct documentation of denial type, the use of accurate grade level and appropriate denial language using the most current health plan specific, approved denial templates following the applicable state and federal requirements. Assists with and coordinates various quality improvement projects/programs.
- This role has flexibility for the right candidate to work out of any of our 6 regions.*
Primary duties may include but are not limited to:
- San Gabriel Valley (Region 1)
- Downtown LA (Region 2)
- South Bay (Region 3)
- Long Beach Area (Region 4)
- San Fernando Valley (Region 5)
- Orange County (Region 6)
Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners’ (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer.
Provides support by presenting quarterly on issues/topics related to Utilization Management (UM) including delegation, regulatory requirements, policies, recommendations regarding compliance and utilization/quality issues related to home health and/or durable medical equipment.
Responds in writing to all health plan UM requests and determines how best to meet these requests.
Manages, coordinates and facilitates annual health plan audits of components within the HCP corporate and network organizations. Responds in writing to correct any deficiencies.
Assists and facilitates consistency and compliance of Utilization Management in accordance with health plan, CMS and NCQA requirements. Assists and makes recommendations for any revisions to the UM plan to meet these requirements.
Identify opportunities for improvement in UM processes with UM Director to develop improvement plans and training programs
Assists the Regional Utilization Management departments in the development of the denials process.
Reviews and assists Physician Reviewers in composing denial reasons to ensure the denial reason language is clear and concise and citing correctly
Monitors referral turnaround time to meet health plan regulatory compliance.
Oversees the processing and submission of all denial letters region-wide and ensures that denial turnaround times meet health plan regulatory compliance.
Develops UM tools to maintain UM and monitor regulatory compliance.
Participates in the development and implementation of enhancements to the Referral management system.
Develops and/or updates the Utilization Management departmental policies and procedures.
Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Performs additional duties as assigned.
Degree from a two-year college/ bachelor’s degree preferred.
Graduate from an accredited school of Nursing.
Current California RN license.
Prior clinical experience preferably in an acute care, clinical setting
3 years of utilization review experience required.
Knowledge of MGC guidelines
3 years management experience, preferably in a medial group / IPA or HMO setting.
HMO/ Health plan. Experience a plus.
Previous Medicaid experience a plus
MGC guideline certification a plus
KNOWLEDGE, SKILLS, ABILITIES:
Proficient in Microsoft applications (Word, Excel, PowerPoint, Access).
Excellent verbal and written communication skills.