Utilization Management Specialist
1 week ago
This is a challenging and rewarding role that requires a strong background in healthcare operations and management. As a Utilization Manager at APLA Health, you will be responsible for overseeing the daily operations of our Utilization Management (UM) program, ensuring that all processes and programs are fully implemented and compliant with internal, government, health plan/IPA, and medical group requirements.
Key Responsibilities- Develop and implement a standardized Utilization Management Program to ensure compliance with regulatory requirements.
- Ensure staff competency through training and inter-rater reliability tools.
- Develop, implement, and maintain policies and procedures for medical utilization management functions.
- Establish and maintain excellent working relationships with internal and external constituents, including the Chief Medical Officer, clinic directors, and site medical directors.
- Collaborate with the Quality Director to identify opportunities for process improvements in Utilization Management.
- Develop and implement utilization management programs to facilitate the use of appropriate medical resources and reduce financial exposure.
- Compile and review reports on work function activities to identify utilization trends and make recommendations to management.
- Communicate with staff to convey health plan, contract, or operations information to ensure a consistent knowledge base.
- Supervise a team of referral coordinators, patient engagement and retention specialists, and medical records coordinators.
- Optimize processes and workflows for the UM staff.
- Five years' experience in utilization/care management in a clinical or managed care setting.
- Four years' management/supervisory experience.
- Bachelor's degree in Nursing (RN with active California certification) or other healthcare-related field.
- Basic computer skills in a Windows operating environment, including Microsoft Word, Excel, and email.
- Dynamic leadership, excellent verbal and written communication skills, and strong operations experience.
This is primarily an office position that requires occasional bending, reaching, stooping, lifting, and moving of office materials weighing 25 pounds or less.
The position requires daily use of a personal computer and requires entering, viewing, and revising text and graphics on the computer terminal and on paper.
Equal Opportunity EmployerAPLA Health is an equal opportunity employer and welcomes applications from diverse candidates.
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