Utilization Review Supervisor

2 weeks ago

San Jose, United States The County of Santa Clara Full time

**Salary**
- $194,234.56 - $248,456.00 Annually**Location**
- San Jose Metropolitan Area, CA**Job Type**
- Full-Time**Job Number**
- 24-S1M-A**Department**
- Valley Health Plan**Opening Date**
- 06/06/2024**Closing Date**
- 6/21/2024 11:59 PM Pacific**Bargaining Unit**
- 92**Description**:
Under direction, to organize, direct, and supervise the Utilization Review functions as required by Federal and State regulations and the Valley Health Plan (VHP) Utilization Review department.

**Typical Tasks**:
The following is a descriptive list of the range of duties performed by employees in this classification and is not intended to reflect all duties performed by every incumbent in this classification:

- Directs, evaluates, and develops systems and procedures to meet the goals and objectives of the Utilization Review department for VHP;
- Evaluates the compliance of the Utilization Review functions in terms of state-mandated standards and regulations, and offers solutions and efficiencies to improve compliance with required regulations;
- Supervises, directs, trains, and evaluates utilization review staff, which is comprised of clinical and non-clinical team members;
- Prepares work schedules and makes assignments;
- Attends meetings as required;
- Evaluates Utilization Review policies and procedures and makes recommendations regarding such;
- Prepares and submits reports as required;
- Acts as a technical resource for VHP staff as it relates to Utilization Review;
- May be assigned as a Disaster Service Worker, as required;
- other related duties, as required.

**Employment Standards**:
**Experience Note**:The required knowledge and abilities are attained through possession of an Associate’s Degree in Nursing, Health Care Administration, or a related field,

andFive (5) years of nursing or utilization management, case management, or equivalent experience in a managed care/HMO environment or patient care setting, and one (1) year of lead and/or supervisory experience. The lead and/or supervisory experience may be inclusive of the nursing or utilization management, case management, or equivalent experience.
- ORPossession of a Bachelor's Degree in Nursing, Health Care Administration, or a related field,
- andThree (3) years of nursing or utilization management, case management, or equivalent experience in a managed care/HMO environment or patient care setting, and one (1) year of lead and/or supervisory experience. The lead and/or supervisory experience may be inclusive of the nursing or utilization management, case management, or equivalent experience.
- Possession of a Master's Degree in Nursing, Health Care Administration, or a related field may substitute for one (1) year of the required patient care or managed care/HMO experience.
- **Special Requirements**
- Possess and maintain a valid California Registered Nurse License.
- Possession of a Utilization or Case Management certification is highly desired.
- Ability to travel to alternate locations in the course of work. If driving, possession of a valid California driver’s license prior to appointment and the ability to qualify for and maintain a County driver authorization.

**Knowledge of**:

- Hospital organization, operations, and procedures;
- Principles of supervision and program management;
- Federal and State health care laws and regulations common to the operation of hospitals in California;
- Regulations of intermediary agencies pertaining to hospital stay coverage (e.g., Medicare/Medi-Cal);
- Medical terminology and related levels of care and treatment;
- Policy and procedure development;
- Role of the public teaching hospital;
- Evaluation and assessment techniques.

**Ability to**:

- Analyze, develop, and implement effective reporting systems and procedures;
- Analyze, interpret, apply, and implement Federal and State rules and regulations;
- Collect and record data;
- Act as a technical resource to physicians and Utilization Review staff;
- Supervise, plan, and assign workload of Utilization Review staff;
- Evaluate data and statistics;
- Work independently to set priorities and make effective decisions;
- Communicate effectively in English, both orally and in writing;
- Establish and maintain effective working relationships with those contacted in the course of work, at all levels, including colleagues, the public, and other agencies.

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