Current jobs related to Director of Utilization Management - Bakersfield - Impresiv Health
-
Director of Utilization Management
1 month ago
Bakersfield, United States All’s Well Full timeAre you a visionary leader with a passion for enhancing healthcare quality and efficiency? Our rapidly growing managed care company in Bakersfield, California, is seeking an experienced Medical Director to helm our Utilization Department. This pivotal role requires a dynamic individual with extensive experience in managed care, utilization management, and a...
-
Director Utilization Management
4 weeks ago
Bakersfield, California, United States Dignity Health Full timeOverviewThis position is remote within California, Nevada or Arizona, with a clear and current CA RN license.*The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric full-service management service organization structure. We offer a menu of management and business services...
-
Director of Utilization Management
3 weeks ago
Bakersfield, United States Impresiv Health Full timeTitle: Director of Utilization Management Duration: Direct Placement Location: Bakersfield, CA Summary: The Director of Utilization Management (UM) provides comprehensive oversight of the Utilization Review process. The position integrates and coordinates services using continuous quality improvement initiatives to promote positive...
-
Director Utilization Management
4 weeks ago
Bakersfield, United States Dignity Health Full timeOverview This position is remote within California, Nevada or Arizona, with a clear and current CA RN license.* The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric full-service management service organization structure. We offer a menu of management and business...
-
Utilization Management Director
6 days ago
Bakersfield, California, United States Impresiv Health Full timeImpresiv Health is seeking a highly motivated and experienced Utilization Management Director to lead our team in ensuring efficient and effective healthcare delivery. As a key member of our leadership team, you will play a vital role in developing and implementing strategies that optimize resource utilization, enhance patient care outcomes, and drive...
-
Chief of Utilization Oversight
4 days ago
Bakersfield, California, United States Impresiv Health Full timePosition: Director of Utilization Management Employment Type: Direct Placement Location: Bakersfield, CA Overview: The Director of Utilization Management (UM) is responsible for the comprehensive administration of the Utilization Review process. This role involves the integration and coordination of services through continuous quality...
-
Vice President of Utilization Oversight
1 week ago
Bakersfield, California, United States Impresiv Health Full timeTitle: Director of Utilization Management Duration: Direct Placement Location: Bakersfield, CA Overview:The Director of Utilization Management (UM) plays a pivotal role in supervising the Utilization Review process. This position is responsible for integrating and coordinating services through continuous quality improvement initiatives aimed at enhancing...
-
Program Director
3 months ago
Bakersfield, United States Integrated Practice Management LLC Full timeJob DescriptionJob DescriptionDescription:Under the general supervision of the Chief Nursing Officer, the Program Director provides clinical/ guidance, support and development to the therapists, interns, addiction counselors, unlicensed case managers and mental health team. To provide insight, guidance, and leadership in developing and maintaining a...
-
Utilization Review Nurse
1 week ago
Bakersfield, United States Kern Medical Full timeKern Medical has been a community cornerstone since its founding in 1867. Today, we are an acute care teaching center with 222 beds, offering the only advanced trauma care between Fresno and Los Angeles. Kern Medical offers a range of primary, specialty, and multi-specialty services including high-risk pregnancy care, inpatient psychiatric services...
-
Utilization Review Nurse
2 months ago
Bakersfield, United States Kern Medical Full timeKern Medical has been a community cornerstone since its founding in 1867. Today, we are an acute care teaching center with 222 beds, offering the only advanced trauma care between Fresno and Los Angeles.Kern Medical offers a range of primary, specialty, and multi-specialty services including high-risk pregnancy care, inpatient psychiatric services integrated...
-
Director of Software Engineering
4 weeks ago
Bakersfield, United States Healthcare Finance Direct LLC Full timeJob DescriptionJob DescriptionDescription:Are you EPIC?Do you have the ability to demonstrate, understand and apply HFD’s core purpose andvalues in all that you do? At HFD our core purpose is to help the underserved live healthier. In order to accomplish this mission, we must ensure that our team is aligned with our E.P.I.C. values: Excellence: Always...
-
Regional Director
24 hours ago
Bakersfield, California, United States RadNet Bakersfield (Kern-Radiology) Full timeAbout RadNet Bakersfield (Kern-Radiology)We are a leading provider of high-quality radiology services, dedicated to delivering exceptional patient care and advancing the field of radiology.Job SummaryWe are seeking a highly skilled and experienced Regional Manager to join our team at RadNet Bakersfield (Kern-Radiology). As a Regional Manager, you will be...
-
Travel Nurse RN Utilization Review
1 day ago
Bakersfield, California, United States Talent4Health Full timeTalent4Health is seeking a travel nurse RN Utilization Review professional to join our team in a travel nursing role in California.Job Summary:We are looking for a skilled travel nurse RN Utilization Review professional to work with our clients in California. The ideal candidate will have experience in utilization review and discharge planning, as well as...
-
RN Inpatient Acute Case Management
4 weeks ago
Bakersfield, United States Heritage Provider Network Full timeJob Description Under the direction of the Vice President Hospital Based Services Inpatient / Outpatient, this position is responsible to Provide guidance and coordination for Utilization Review Department. Evaluate inpatient medical records using criteria and facilitate discharge plans and needs. The RN or LVN Inpatient Acute Case Manager will interact with...
-
Licensed Vocational Nurse Case Manager
1 week ago
Bakersfield, California, United States Integrated Practice Management LLC Full timePosition OverviewThe Licensed Vocational Nurse (LVN) Case Manager plays a crucial role in addressing both clinical and non-clinical requirements of members with significant health challenges. This position emphasizes a systematic, community-oriented, interdisciplinary approach to high-touch, person-centered care management.Key ResponsibilitiesThe LVN Case...
-
Licensed Vocational Nurse Case Manager
4 days ago
Bakersfield, California, United States Integrated Practice Management LLC Full timePosition OverviewThe Licensed Vocational Nurse (LVN) Case Manager plays a crucial role in addressing both clinical and non-clinical requirements of members with significant health challenges. This position emphasizes a systematic, community-oriented, interdisciplinary approach to care management, focusing on personalized and high-touch interactions.Key...
-
Promotions Director-KMYX
3 months ago
Bakersfield, United States Chavezfoundation Full timeThe Promotions Director for KMYX-Bakersfield, CA proactively manages all the Marketing and Promotion activities for KMYX. Responsibilities: Develop and execute the Quarterly Marketing Strategy for KMYX. Work monthly to track expenses and adhere to expense guidelines. Manage the promotion and marketing budget not to exceed expenses unless preapproved by the...
-
Director of Educational Services
1 month ago
Bakersfield, California, United States California Department of Education Full timeRequirements/Qualifications Statement of Faith consistent with vision and mission of the school; A minimum of 5 years experience at a secondary school or private, faith based institution is preferred. About the Employer The educational experience at BCHS seeks to develop each student's mind, body and spirit to his or her fullest potential through challenging...
-
Acute Care Case Management Registered Nurse
1 week ago
Bakersfield, California, United States Heritage Provider Network Full timeJob Overview Under the supervision of the Vice President of Hospital-Based Services, this role is tasked with overseeing the Utilization Review Department. The RN or LVN in Acute Care Case Management will evaluate inpatient medical records using established criteria and facilitate discharge planning and requirements. This position requires interaction with...
-
Wildland Firefighter
24 hours ago
Bakersfield, California, United States Bureau of Land Management Full timeJob SummaryWe are seeking a highly skilled and experienced Wildland Firefighter to join our team at the Bureau of Land Management. As a Wildland Firefighter, you will play a critical role in preventing and suppressing wildfires, while also working to protect people, property, and the environment.Key ResponsibilitiesLead and direct suppression operations on...
Director of Utilization Management
2 months ago
Title: Director of Utilization Management
Duration: Direct Placement
Location: Bakersfield, CA
Summary:
The Director of Utilization Management (UM) provides comprehensive oversight of the Utilization Review process. The position integrates and coordinates services using continuous quality improvement initiatives to promote positive member outcomes. Frequent executive level reporting and tracking on department and individual team productivity is essential. The Director of UM assesses needs, plans, communicates, designs services and strategies to forward the mission and serve member needs. The Director provides strategic leadership, development, and supervision to utilization review department, provides inter-professional collaboration with facility-based case managers and discharge planners, and coordinates with all aspects of the Kern Health Systems functions, including Claims and Member Service, to provide guidance on complex Authorizations, Referrals, Denials and Appeals.
Under the direction of the Utilization Management Medical Director, and in collaboration with the Chief Medical Officer, Sr. Director of Health Services, and the Director of UM assists in coordinating clinical functions and programs which effectuate and support client medical policy according to contractual requirements, and in developing and implementing new clinical programs to manage costs and ensure quality care delivery. The position will be an essential contributor to the development, implementation, and monitoring of the medical management strategy and ongoing process improvement.
What You Will Do:
- Oversees formal utilization and network coordination services. Provides operational oversight and recommends corrective action for all shared services.
- Manages the UM results, including referral management; acute, SNF and Rehab admissions.
- Continually creates and implements strategies to improve organizational and UM Departments performance.
- Participates in contracted provider network meetings to enhance communication and continuity of member care services.
- Has management responsibility as assigned for the key Medical Management Programs, Coordinated Care, DME, Ancillary services, and Pharmaceutical collaboration.
- Participates in determination of department's goals and objectives, setting organizational structure, staffing, and space planning.
- Participates in recruitment, retention, and training of UM Management staff.
- Acts as a resource to other departments in regard to Case Management, Disease Management, Health Education, Quality Improvement, Compliance, Provider Network Management, and Claims.
- Collaborates with Executive leadership of Medical Management, Medical Directors, UM Management, and other staff as well as other departmental peers.
- Program Development, Implementation and Evaluation.
- Conduct needs assessment including development of methods for determining potential patient enrollment, medical literature review, analysis of pre-program utilization and return on investment.
- Development and Implementation of the UM Program to include establishment of policies and procedures, enrollment strategies, member and physician materials, and measurements of program outcome.
- Evaluate staff educational needs and coordinate training.
- Analytical ability for problem identification and assessment and evaluation of data/statistics obtained from an ongoing review process.
- Knowledge of Milliman Care Guidelines (MCG), InterQual Criteria, MCAL and CMS Criteria.
- Knowledge of managed care health plans operations and HIPAA guidelines.
- Experience and knowledge in intermediate computer skills (i.e. Microsoft Word, Excel).
- Leads and participates in cross functional corporate teams which design and implement new population management programs.
- Develops and implements process and program redesigns.
- Leads multiple teams of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources.
- Ability to utilize multiple technology systems for documentation and coordination of services.
- Ensures adherence to all contract, regulatory and accreditation requirements.
- Develops short/long-term objectives and monitors processes and procedures to ensure consistency with the enterprise and compliance with state and federal regulations.
- Collaborates with community partners to resolve issues or find solutions.
- Manages budget and special projects.
- Hires, trains, coaches, counsels, and evaluates performance of direct reports.
- Serves in a supportive role as a member of the Physician's Advisory, Quality Improvement and Utilization Management, Compliance, Fraud, Waste and Abuse, Delegated Oversight, and Pharmacy & Therapeutics Committees.
- Responsible for detailed utilization analysis and benchmarking.
- Encourages staff in growth opportunities, in-services, seminars, etc.
- Directs, coordinates and evaluates efficiency and productivity of utilization management functions for physical and behavioral health services (mental health and applied behavioral analysis).
- Develops a comprehensive orientation program for all new employees in the UM Department.
- Establishes and monitors a after-hours clinical triage programs to provide assistance to members in obtaining appropriate medical care outside standard office hours.
- Collaborates with network leaders to design and operationalize successful methods for working with hospitals, home health, and other ancillary services.
- Assist in the review and updating of Policy and Procedures
- Coordinates with Health Services leadership in identifying inappropriate utilization of services for over and underutilization.
- Coordinates with Provider Network Management on referral and inpatient activity where provider behavior needs to be addressed or provider feedback/input is required.
- Reviews and approves Notice of Action (NOA) letters and Letters of Agreement (LOA) for non-contracted providers and facilities, ensuring appropriate alternatives have been considered for contracted services.
- Evaluates, assesses, coordinates, and initiates processes towards NCQA accreditation in the areas of Utilization Management.
- Interviews, selects, trains, develop, and evaluate staff; provides input to management regarding disciplinary issues, including Performance Improvement Plans (PIP).
- Performs other job-related duties as required.
- Adheres to all company policies and procedures relative to employment and job responsibilities.
You Will Be Successful If:
- Strong knowledge of the principles, techniques and practice of public and community health education, including the understanding of the theory and ability to apply knowledge of the basis of human behavior, the process of education, motivation and group work, and the relationships of cultural patterns of human behavior.
- Demonstrated knowledge of and skill in protocols of Disease Management.
- Strong knowledge of common patient disease processes and usual methods of treating them.
- Knowledge of medical terminology and commonly used equipment.
- Knowledge of DRG, ICD 9 and/or CPT coding.
- Ability to supervise and mentor staff, analyze situations independently and make appropriate decisions.
- Ability to prepare written reports and maintain accurate records.
- Strong analytical, assessment and problem-solving skills with intermediate negotiation skills.
- Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individuals at all levels both inside and outside of client.
- Ability to use tact and diplomacy to diffuse emotional situations.
- Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards.
- Advanced computer skills that include MS Office products.
- Demonstrated ability to commit to and facilitate an atmosphere of collaboration and teamwork.
- Demonstrate ability to respect and maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to, patient healthcare, client business or employee information and make no disclosure of such information except as required in the conduct of business.
- Demonstrated ability to multi-task in an interrupt-driven environment and complete assignments on a timely basis.
- Strong attention to detail; work accurately and at a reasonable rate of speed.
What You Will Bring:
- Bachelors (BSN) from an accredited college or University in Nursing (BSN) or other relevant health care field required. Master's degree (MSN) preferred.
- Possession of Current, active and unrestricted RN license for the state of California
- Minimum of Five (5) years of management level experience in Utilization Management in a managed care environment or healthcare industry.
- Minimum of five (5) years' clinical experience in Utilization Review or Case Management in a Health Plan or similar payer/provider setting (Hospital, Managed Care network, etc.) and with community-based programs.
- Experience with Utilization Management in a managed care environment; basic procedures utilized in claims processing in a managed care environment; medical reimbursement methodologies; supervisory and training techniques. Thorough knowledge of regulations and requirements related to utilization management (UM) Experience with QA/QI and program development/process improvement.
- Possession of valid driver's license and proof of State required auto liability insurance. Required Travel Up to 20% Bilingual (English/Spanish) preferred.
- Adapt to a rapidly evolving work environment; work independently and manage multi-task responsibilities; communicate with a variety of personnel and providers; establish and maintain appropriate quality improvement and utilization management programs; make decisions within a managed care environment; prepare a variety of statistical and narrative reports; effectively supervise and train staff.