Utilization Management Director
10 hours ago
We are seeking a highly skilled Utilization Management Director to join our team at APLA Health. As a key member of our healthcare operations team, you will be responsible for managing the daily operations of Utilization Management (UM) at APLA Health and Wellness (APLAHW).
Key Responsibilities- Develop and implement a standardized Utilization Management Program to ensure compliance with internal, government, health plan/IPA, and medical group requirements.
- Ensure staff competency through inter-rater reliability tools and evidence-based criteria for utilization review.
- Develop, implement, and maintain compliance, policies, and procedures regarding 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.
- Participate in the collection, analysis, and reporting of data relevant to utilization management.
- Collaborate with the Quality Director to identify opportunities for process improvements in Utilization Management that align with the organization's vision and strategic long-term goals.
- Develop, implement, and maintain utilization management programs to facilitate the use of appropriate medical resources and minimize financial exposure.
- Compile and review reports on work function activities for statistical and financial tracking purposes to identify utilization trends and make recommendations to management.
- Communicate with staff to convey health plan, contract, or operations information to ensure a consistent and appropriate knowledge base for performing duties.
- Promote staff growth and development by identifying educational opportunities to increase efficiency and maintain compliance with industry standards.
- Supervise a team of referral coordinators, patient engagement and retention specialists, and medical records coordinators.
- Optimize processes and workflows for the UM staff.
- Ensure referrals staff meet key quality and risk management goals and referrals are properly tracked.
- Hire and train new UM staff as needed.
- Manage the medical group's referral filter tool and flag questionable referrals for further evaluation by the site medical director.
- Supervise staff monitoring patients in emergency departments and hospitals in real-time and ensure patients receive appropriate follow-up by clinical staff.
- Ensure high-utilizing patients are appropriately engaged in case management programs.
- Report key UM metrics at monthly agency quality meetings.
- Lead monthly UM committee meetings.
- Five years' utilization/care management experience in a clinical or managed care setting preferred.
- Four years' management/supervisory experience (in a formal or informal role) preferred.
- Requires a Bachelor's degree in Nursing (RN with active California certification) or other healthcare-related field like MPH, MHA, MBA/MS in healthcare-related field.
- Basic computer skills in a Windows operating environment, including Microsoft Word, Excel, and an email system.
- Must be a dynamic leader, able to navigate a complex environment, with excellent verbal and written communication skills, as well as strong operations experience.
- Effective influencing, negotiation, relationship-building, and communication skills are essential.
- Effective employee management skills.
- Possess strong leadership, critical-thinking, and motivational skills/abilities.
- Excellent problem-solving and organizational skills required.
- Knowledge of InterQual and/or Milliman software preferred.
- Knowledge of electronic health records systems (eClinicalWorks preferred).
- Knowledge of ambulatory healthcare delivery and management.
- Knowledge of NCQA, DMHC, CMS, and other regulatory agency requirements pertaining to delivery of healthcare in the managed care setting.
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.
Special RequirementsMust possess a valid California driver's license; proof of auto liability insurance; and have the use of a personal vehicle for work-related purposes. COVID Vaccination and Booster required or Medical/Religious Exemption.
Equal Opportunity Employer: minority/female/transgender/disability/veteran.
-
Utilization Management Director
3 days ago
Los Angeles, California, United States Management Business Solutions Full timeJob Title: Utilization Management DirectorManagement Business Solutions is seeking a highly skilled Utilization Management Director to join our team. As a key member of our healthcare operations team, you will be responsible for managing the day-to-day operations of the Utilization Management Program in the Service Area or a Medical Center.Key...
-
Utilization Management Program Director
2 weeks ago
Los Angeles, California, United States Management Business Solutions Full timeJob Title: Utilization Management Program DirectorManagement Business Solutions is seeking a highly skilled Utilization Management Program Director to lead our team in providing exceptional patient care and ensuring cost-effective utilization of resources.Key Responsibilities:Develop and maintain policies and procedures for Utilization ManagementCollaborate...
-
Director of Utilization Management
3 weeks ago
Los Angeles, California, United States healthcarerecruitmentpartners Full timeDirector of Utilization ManagementThe Director of Utilization Management plays a pivotal role in overseeing the Case Management and Utilization Review program. This individual is responsible for developing and managing programs that emphasize appropriate admissions, concurrent and retrospective review of care, and other integrated functions such as Discharge...
-
Outpatient Utilization Manager
3 weeks ago
Los Angeles, California, United States MedPOINT Management Full timeJob SummaryWe are seeking a highly skilled Outpatient UM Clinician to join our team at MedPOINT Management. As a key member of our Utilization Management department, you will play a critical role in ensuring that our members receive high-quality, cost-effective care.Key ResponsibilitiesReview and process precertification requests for medical necessity,...
-
Director of Utilization Management
3 days ago
Los Angeles, California, United States Kaiser Permanente Full timeJob SummaryAs a key member of our team, the Director of Utilization Management will be responsible for developing and managing programs that emphasize appropriate admissions, concurrent and retrospective review of care, and other integrated functions to promote a centralized, coordinated, interdisciplinary process in the continuum of care.Key...
-
Director of Utilization Management
2 days ago
Los Angeles, California, United States Kaiser Permanente Full timeJob SummaryAs a key member of our team, the Director of Utilization Management will be responsible for developing and managing programs that emphasize appropriate admissions, concurrent and retrospective review of care, and other integrated functions to promote a centralized, coordinated, interdisciplinary process in the continuum of care.Key...
-
Utilization Management Program Director
3 days ago
Los Angeles, California, United States Kaiser Permanente Full timeJob Summary:As a key member of the Kaiser Permanente team, the Utilization Management Program Director plays a vital role in ensuring cost-effective and quality patient care. This position oversees the day-to-day operations of the Utilization Management Program, collaborating with multidisciplinary teams to plan and coordinate care across the continuum. The...
-
Los Angeles, California, United States Healthcare Recruitment Partners Full timeJob SummaryHealthcare Recruitment Partners is seeking a highly skilled Director of Utilization Management and Case Coordination to lead our team in Los Angeles, California. As a key member of our organization, you will be responsible for directing the Case Management and Utilization Review program, developing and managing programs that emphasize appropriate...
-
Utilization Management Program Director
4 weeks ago
Los Angeles, California, United States Recruitics JB Full timeJob Summary:As a key member of the Recruitics JB team, we are seeking a skilled Utilization Management Program Director to lead our Utilization Management Program in the Service Area or a Medical Center. This role is responsible for ensuring cost-effective and quality patient care by appropriate utilization of resources. The ideal candidate will provide...
-
Utilization Management Program Director
2 days ago
Los Angeles, California, United States Kaiser Permanente Full timeJob Summary:As a key member of the Kaiser Permanente team, the Utilization Management Program Director will oversee the day-to-day operations of the Utilization Management Program in the Service Area or a Medical Center. This role is responsible for ensuring cost-effective and quality patient care by appropriate utilization of resources. The successful...
-
Director of Utilization Management
1 week ago
Los Angeles, California, United States Kaiser Permanente Full timeJob SummaryDevelops, manages, and directs the Utilization Management programs in a Service Area or a Medical Center. Develops and manages programs that emphasize appropriate admissions, concurrent, and retrospective review of care. May also be responsible for other integrated functions such as Discharge Planning, Case Management program, Outside Utilization...
-
Healthcare Manager
3 days ago
Los Angeles, California, United States Management Business Solutions Full timeJob SummaryManagement Business Solutions is seeking a skilled Healthcare Manager to lead our Utilization Management Program. As a key member of our team, you will be responsible for managing the day-to-day operations of the program, ensuring cost-effective and quality patient care through appropriate resource utilization.Key Responsibilities:Develop and...
-
Utilization Management Specialist
3 weeks ago
Los Angeles, California, United States APLA Health Full timeJob SummaryThis 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...
-
RN Manager of Utilization Management
3 weeks ago
Los Angeles, California, United States healthcarerecruitmentpartners Full timeRN Manager of Utilization Management Job SummaryThe RN Manager of Utilization Management is a key role in our healthcare organization, responsible for overseeing the coordination of services through an interdisciplinary process. This position requires a strong leader who can balance individually identified patient and family needs with cost-effective...
-
RN Manager of Utilization Management
1 week ago
Los Angeles, California, United States healthcarerecruitmentpartners Full timeRN Manager of Utilization Management Job SummaryWe are seeking a skilled RN Manager of Utilization Management to oversee the coordination of services through an interdisciplinary process. The ideal candidate will have a strong background in case management and be able to assess patients to determine the appropriate level of care.Key...
-
RN Manager of Utilization Management
3 days ago
Los Angeles, California, United States healthcarerecruitmentpartners Full timeRN Manager of Utilization Management Job DescriptionJob Summary:The RN Manager of Utilization Management is responsible for overseeing the coordination of services through an interdisciplinary process across the continuum of care. This role expands the Care Management focus, balancing individually identified patient and family needs with cost-effective...
-
Los Angeles, California, United States Blue Shield of CA Full timeYour RoleAs a key member of the Utilization Management team at Blue Shield of California, you will play a critical role in delivering and collaborating on all aspects of utilization management and care coordination for Commercial membership.This position requires a strong leader who can provide direction and leadership in compliance to regulatory...
-
Utilization Management Nurse Senior
2 weeks ago
Los Angeles, California, United States Blue Shield of CA Full timeJob Title: Utilization Management Nurse, SeniorAbout the Role:The Utilization Management Nurse, Senior will play a critical role in ensuring that our members receive the most appropriate care possible. As a member of the Utilization Management team, you will be responsible for reviewing inpatient stays to determine medical necessity and ensuring that our...
-
Utilization Management Nurse Senior
4 weeks ago
Los Angeles, California, United States Blue Shield of CA Full timeJob SummaryWe are seeking a highly skilled Utilization Management Nurse, Senior to join our team at Blue Shield of CA. As a key member of our Utilization Management team, you will play a critical role in reviewing inpatient stays for our members and ensuring that nationally recognized levels of care are applied correctly.Key ResponsibilitiesPerform...
-
Utilization Management Nurse Senior
4 weeks ago
Los Angeles, California, United States Blue Shield of CA Full timeJob SummaryWe are seeking a highly skilled Utilization Management Nurse, Senior to join our team at Blue Shield of CA. As a key member of our Utilization Management team, you will play a critical role in reviewing inpatient stays for our members and ensuring that nationally recognized levels of care are applied correctly.Key ResponsibilitiesPerform...
