Healthcare Operations Manager
4 days ago
Express Healthcare seeks a dedicated Utilization Management professional to oversee day-to-day operations within our Quality Improvement framework.
Job SummaryWe are looking for an experienced RN Utilization Manager to optimize processes, ensure effective and timely care management, and monitor continuity, necessity, and cost-effectiveness across medical, behavioral, and community health services.
Key Responsibilities- Care Coordination: Collaborate with clinical department managers to align member services with patient needs, monitoring continuity and assessing timeliness, cost-effectiveness, and medical necessity.
- Outlier and Disability Monitoring: Identify high-cost or outlier cases, coordinating actions to minimize organizational risk and liability.
- Data Evaluation and Reporting: Assess data to identify utilization trends, pinpointing overuse or underuse of services, and evaluate member demographics to uncover patterns and design community interventions to improve health outcomes.
- Committee Support and Recommendations: Prepare materials for UM Workgroup/Committee meetings and relay UM Workgroup recommendations to the Provider Advisory Committee for review and approval.
- Individualized Care Planning: Partner with clinical managers and inpatient coordinators to create personalized, integrated care plans as needed for individual members.
- Performance Improvement and QI Initiatives: Gather UM data for use in performance evaluations and QI initiatives to meet program standards.
Minimum requirements include 3-5 years of experience in Utilization Management, a State of Hawaii RN License, Current BLS Certificate, and familiarity with Medicaid and Medicare regulations.
CompensationThe estimated salary for this position is $85,000 per year, based on industry standards and location.
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