Rn Director Utilization Management Inpatient

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health’s Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups hospitals health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options including medical dental and vision plans for the employee and their dependents Health Spending Account (HSA) Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.

This position is work from home within California.

Position Summary:

The Director of Utilization Management for In-Patient is the senior lead over the Utilization Management teams on the overall function of inpatient, hospital transfers and discharge planning. They are responsible for the all department daily operations of the UM administrative and nursing teams for inpatient. Will partner closely with all clinical services leaders within Dignity Health MSO.
The UM director of In-Patient is also responsible for the oversight of Utilization Management auditing, both internal and external as it pertains to their oversight, for all Dignity Health MSO service areas as well as the development of UM work plans for submission to health plans as needed. They are the operational lead for bringing on new lines of business into the UM workflow. The Director is responsible for reviewing and providing program metrics to senior leadership as well as analysis of program and utilization statistics as well as delivering reporting to both UM and quality committee meetings. The director has direct leadership over teams of managers and direct reports across the service area.

Responsibilities may include:
- Provide leadership and oversight of Utilization Management teams in both local and remote locations for inpatient functions. Partner closely with the Director of UM / Pre-Service for across the board collaboration.
- Ensure that all Utilization Management staff is properly trained in the UM workflow and/or interqual as appropriate and has the correct tools to perform their function.
- Continuously evaluate programs, reporting tools, and workflows to make recommendations to effect improvement in outcomes as identified.
- Report on outcomes and program metrics to Utilization Management teams and senior leadership.
- Lead team of managers and direct reports in Utilization Management teams across service areas.
- Identify staffing needs and assist with recruitment and selection of Utilization Management team members.
- Evaluate and complete health plan work plans to meet timely submission.
- Responsible for oversight and completion of all health plan audits across all service areas.
- Effectively and efficiently onboard and integrate new service areas to the UM workflow.
- Work closely with service area medical directors to identify workflow changes and review level changes to support efficiency and maintain strong clinical management.
- Serves as a required member of UM committee meetings.
- Reports UM metrics to quality committees as needed.
- Monitor for consistent application of UM criteria by staff, for each level and type of UM decision.
- Monitor documentation for adequacy.
- Perform other duties as assigned.

Minimum Qualifications:

- 5 years progressive leadership experience in overall Case Management, with a focus on in-patient UM functions.
- Master's degree in nursing or experience equivalent required
- Clear and current CA Registered Nurse (RN) license
- Knowledge of federal, state and local healthcare related laws and regulations; ability to comply with these in healthcare practices and activities.
- Knowledge of the factors contributing to quality patient care, and the ability to influence these factors in a positive way.

Preferred Qualifications:

- Experience with inpatient UM within a Management Services Organization (MSO) organization and/or Health Plan strongly preferred.

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