UTILIZATION REVIEW MANAGER

County of Contra Costa, California - Martinez, CA (30+ days ago)3.6


Supervises and trains subordinate staff in methods and practices pertinent to their assignments
Confers with subordinates regarding dispositions of problems
Interviews, selects, hires, orients, evaluates, counsels and recommends discipline of subordinate staff
Reviews and analyzes governmental and accrediting agency standards governing admissions, treatment and continued stay of patients to develop policies and procedures
Reviews patient treatment plans to ensure adherence to established criteria and standards
Assists review committee in planning and holding federally mandated utilization reviews, periodic medical reviews and professional reviews

When Assigned to Contra Costa Regional Medical Center:
Refers cases to Utilization Review Committee for review and course of action when case fails to meet criteria
Analyzes individual patient records to determine validity of admission
Serves as review committee liaison with other hospital committee in development of policies and procedures
Supervises and coordinates activities of utilization review staff in maintenance of informed policy and procedure manuals, files, records and correspondence
Keeps informed of patient disease processes and treatment modalities through reading clinical literature

When Assigned to Contra Costa Health Plan:
Oversees and participates in the development and implementation of effective and efficient standards, policies, protocols, processes, reports and benchmarks that support and further enhance utilization management and timely access to care
Provide guidance on issues related to referral and authorization process, benefits interpretation, and other utilization issues
Prepare department for internal and external audits, NCQA accreditation, and conduct utilization management delegation audits
Accountable for the oversight of delegated entities' utilization management and access to care; performs annual oversight audits

When Assigned to the Behavioral Health Division:
Develops and implements Utilization Review standards, policies, protocols, and processes to ensure Contra Costa Mental Health Plan (CCMHP) compliance
Evaluates and supervises the response to first level appeals for denial of services to inpatient psychiatric services and claims to the Institution of Mental Diseases (IMD)
Organizes and participates in audits by California Department of Health Care Services (DHCS), External Quality Review Organization (ERQO) and federal agencies including Office of the Inspector General; ensuring the county meets the required standards for compliance, avoidance of disallowance and maintenance of county certification
Provides guidance on authorization process, benefits interpretation, and critical time lines to Community Base Organizations (CBOs) and
County operated clinics; in addition ensuring they meet requirements and are in compliance according to Utilization Management and Utilization Review process
Develops and manages of Utilization Management and Review Plan through the implementation of California State Substance Use Disorder (SUD) waiver program within the Behavioral Health Division's Alcohol and other Drug Services and Mental Health programs.
Minimum Qualifications
License Required: Candidates must possess and maintain throughout the duration of employment: a current, valid and unrestricted license as a Registered Nurse issued by the California Board of Registered Nursing.

Education: Possession of a bachelor's degree in nursing from an accredited college or university.

Experience for Contra Costa Health Plan Assignment: Three (3) years of full-time, or its equivalent, experience as a Registered Nurse in a managed care organization (i.e. HMO), two (2) years of which must have included experience as a Utilization Review Nurse, Discharge Planner, or Case Management Nurse, one (1) year of which must have been in a supervisory capacity.
Experience for Contra Costa Regional Medical Center Assignment: Three (3) years of full-time, or its equivalent, experience as a Registered Nurse in an acute care hospital or hospital based ambulatory care health center, two (2) years of which must have included experience as a Utilization Review Nurse, Discharge Planner, or Case Manager Nurse, one (1) year of which was in the capacity of a Charge Nurse, Supervisor or Lead Nurse.

Experience for Behavioral Health Division Assignment: Three (3) years of full-time, or its equivalent, experience as a Registered Nurse in a behavioral health organization (i.e. Mental Health Outpatient Clinic or Inpatient or Emergency Psychiatric Facility), two (2) years of which must have included experience as a Utilization Review Nurse, Discharge Planner, or Case Management Nurse, one (1) year of supervisory experience.

Substitution for all assignments: Two (2) additional years in a Nurse Supervisor capacity may be substituted for the Bachelor's Degree. A Master's Degree in nursing, hospital or health care administration or closely related field may be substituted for one (1) year of experience as a Registered Nurse. No substitution is allowed for the required one (1) year of supervisory experience.

Other Requirements: A background investigation/fingerprint and/or physical exam may be required prior to the start of employment.

A COMPLETED SUPPLEMENTAL QUESTIONNAIRE IS REQUIRED. AN APPLICATION SUBMITTED WITHOUT THE SUPPLEMENTAL QUESTIONNAIRE WILL BE CONSIDERED INCOMPLETE AND WILL THEREFORE BE DISQUALIFIED.