Utilization Management Director
2 days ago
Golden Coast MSO is a proactive and easy-to-work-with management services organization dedicated to providing exceptional professional services. Our team of managed care professionals in Southern California is committed to prioritizing provider and patient needs.
Job SummaryThe Utilization Management Manager is responsible for overseeing the day-to-day operations of the Utilization Management Program. This includes ensuring efficient and quality patient care through the appropriate utilization of resources. The successful candidate will provide direction to staff, including prior authorization, concurrent review, discharge planning, transportation, and case management.
Key Responsibilities- Maintain and develop UM Department policies and procedures as required, staying up-to-date with industry and CMS regulations.
- Collaborate with multi-disciplinary teams to plan and coordinate care across the continuum.
- Coordinate and manage member care with hospital facilities and providers, identifying risk management and quality of care issues.
- Raise concerns and suggestions to leadership individuals.
- Ensure compliance with Federal, State, Health Plan, NCQA, and internal standards and requirements.
- Provide direction to staff regarding utilization review, care coordination, discharge planning, and other services.
- Assist in conducting statistical studies on utilization trends, patterns, and outcomes.
- Hire, train, coach, and discipline professional and clerical support staff.
- Ensure the department meets all regulatory and quality requirements, including Turn Around Times, Notifications, and Guideline application.
- Support the department in all needs and act as backup to coordinator staff as needed.
- Participate in defining department goals and processes, preparing performance reports, and monitoring KPIs.
- Lead the department to achieve required accuracy and volume standards.
- Lead the department's response to regulatory audits, including policy and procedure preparation, universe preparation, and integrity audits.
- Prepare and submit regulatory reporting as required.
- Prepare departmental Utilization Review Committee presentations and maintain detailed minutes of discussions and decisions.
- Minimum 5 years of experience in utilization management, prior authorization, inpatient, and discharge planning in a managed care/insurance setting.
- BSN or bachelor's degree in a healthcare-related field, such as management or health services administration.
- Registered Nurse License (California) or Licensed Vocational Nurse (California).
- Demonstrated knowledge of operations and healthcare management, including Medicare, MediCal, and other local, state, and federal regulations.
- Knowledge of managed care operations.
- Strong interpersonal, negotiation, and management skills.
- Strong oral and written communication skills.
Golden Coast MSO is an equal opportunity employer committed to creating an inclusive and diverse workplace. We encourage candidates from all backgrounds to apply and join our team.
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