UR Manager

SUMMARY

The Utilization Management Manager leads the utilization review staff and function for KPC healthcare. Determines policies and procedures that incorporate best practices and ensure effective utilization reviews. The Manager manages and monitors both concurrent reviews to ensure that the patient is getting the right care in a timely and cost-effective way. Provides analysis and reports of significant utilization trends, patterns, and impacts to resources. The UM Manager will consult with physicians and other professionals to develop improved utilization of effective and appropriate services.

REQUIREMENTS

• Bachelor's Degree in Nursing, or related field
• Minim of two (2) years leadership and department management experience
• Must have working knowledge of Utilization Management and Care Management procedures in an acute care setting
• Must have working knowledge of computer applications such as Excel, Word, and PowerPoint
• Must have the ability to perform cost-benefit and detailed strategic analysis on data and information sets and develop reports accordingly
• Results-oriented professional management with customer service skills including proven time management, organizational, and prioritization skills
• Must possess excellent verbal and written communication skills and thorough knowledge of processes and details integral to utilization review and clinical documentation improvement
• Must have experience in planning and effectively managing departmental budgets and other fiscal responsibilities
• Must be able to demonstrate ability and skill through prior experience and/or academic expertise in actively leading and managing any large-scale change
• Must have expertise in data management and analysis related to length of stay, case mix, resource utilization, etc. with the intent of identifying opportunities for improvement as well as validating current performance
• Must have current knowledge of federal and health plan audit programs such as CMS RAC and other related audit activities, value-based purchasing programs, readmission and other related oversight programs resulting in denied reimbursements

REQ

PREFERRED QUALIFICATIONS

• Minimum of two (2) years’ experience in case management, social work, utilization review, and discharge planning in an acute care hospital
• National certification of any of the following: CCM (Certified Case Manager), ACM (Accredited Case Manager),
• Working knowledge of Microsoft Power BI
• Experience preparing for and responding to CMS audits
• Experience working in a hospital setting
• Thorough knowledge of Medi-Cal and related regulations
• Thorough knowledge of the principles of statistics