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Clinical Utilization Manager
1 month ago
The Clinical Utilization Manager will be responsible for utilizing clinical judgment in providing utilization management services. The focus will be on providing high-quality, cost-effective care that enables patients to achieve maximum medical improvement while receiving care deemed medically necessary.
Key Responsibilities:
• Conducts retrospective claims review, either in the aggregate or on an individual basis, and provides summaries of findings to the Team Manager UM.
• Evaluates the appropriateness of care through interpretation of benefits as outlined in Title 22, Medi-Cal Provider Manual, DMHC and/or CMS regulatory requirements and PHC policies and procedures for each product line.
• Recommends and coordinates interventions to facilitate high-quality, cost-effective care, monitoring treatment, progress, and outcomes of patients.
• Documents and maintains patient-specific utilization management records in a database and files.
• Assists in the refinement/improvement of the HS programs and participates in continuous process improvement endeavors.
• Works with other PHC departments to resolve issues relating to authorization of medical services.
• Audits medical records as appropriate and performs inter-rater reliability audits as directed by the department manager.
Requirements:
• RN/LVN with 2-3 years of experience, including one year of managed care (utilization management) experience, or an equivalent combination of education and experience.
• General knowledge of managed care with an emphasis on UM preferred.
• Current California RN/LVN license, strong knowledge of nursing requirements in a clinical setting, and knowledge of utilization management programs as related to the use of pre-set criteria and protocols.
• Familiarity with business practices and protocols, with the ability to access data and information using automated systems.
• Ability to work within an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities and meeting deadlines.
• Strong organizational skills, effective telephone and computer data entry skills, and a valid California driver's license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.
Work Environment and Physical Demands:
The Clinical Utilization Manager will work in a cubicle setting, using a computer for most of the day, and will be required to lift, move, or carry objects of varying size, weighing up to 10 lbs. All HealthPlan employees are expected to provide the highest possible level of service to clients, promote teamwork and cooperative effort among employees, maintain safe practices, and abide by the HealthPlans policies and procedures as they may from time to time be updated.
