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Form of work***This position is hybrid in-office and work from home.
Dignity Health Medical Foundation established in 1993 is a California nonprofit public benefit corporation with care centers throughout California. Dignity Health Medical Foundation is an affiliate of Dignity Health – one of the largest health systems in the nation - with hospitals and care centers in California Arizona and Nevada. Today Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers we provide increasing support and investment in the latest technologies finest physicians and state-of-the-art medical facilities. We strive to create purposeful work settings where staff can provide great care while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled qualities that are vital to maintaining excellence in care and service.
***This position is hybrid in-office and work from home.
Position Summary:
Under the guidance and supervision of the department Manager/Director, the Supervisor of Utilization Management is responsible and accountable for coordination of services for Mercy Medical Group and Woodland Clinic Medical Group through an interdisciplinary process that provides a clinical and financial approach through the continuum of care. Promotes the quality and cost effectiveness of medical care by ensuring department staff are applying clinical acumen and the appropriate application of policies and guidelines to Managed Care prior authorization referral requests. Under general supervision this position is responsible for coordinating the daily operations of the UM Pre-Authorization team in order to ensure requests are processed in a consistent and timely manner while observing regulatory guidelines.
Responsibilities may include:
- Responsible for day to day operations of the Pre-Authorization team to include timely response and appropriate evaluation of referral reviews, correct selection of criteria, accurate prep to the UM Physician reviewer when indicated, timely verbal and written documentation, and completion of the file
- Ensures adequate staffing and assignments and adjusts workflow as needed to meet department goals.
- Assists manager with performance activities to include monitoring, coaching, educating, and providing feedback to team.
- Ensures UM Physicians are provided the relevant information needed to accurately review a referral. Fosters the relationship between the Pre-Authorization team and the Medical Director and Physician Reviewers.
- Tracks cost savings from activities over time to evaluate success of programs. Maintains or removes programs based on organization and department goals. Develops reports for leadership as required.
- Implements the Departments Policies and Procedures to remain in compliance with Regulatory Agencies (DMHC, DHS, CMS, NCQA, ICE)
- Supervises the use of established criteria sets (Medicare Guidelines, InterQual, Health Plan Benefit Interpretation Guidelines and Medical Management Policies, and DHMF Utilization Management guidelines and protocols.
- Works with other staff and references ICE to regularly ensure that all required forms and resource manuals are current, updated and in compliance with regulations.
- Coordinates completion of Peer InterRater on an annual basis and summarizes results for the UM Committee, initiating actions as requested.
- Proactively supports the Pre-Authorization team, department, and Organization, participates in all ad hoc meetings and prepares ad hoc reports.
Minimum Qualifications:
- Five or more (5+) year's clinical experience required.
- Three to five (3-5) years Utilization Management (UM) experience required.
- One to three (1-3) years charge/lead/supervisory/management experience required. Ablility to demonstrate leadership and management skills.
- Graduate of an accredited school of nursing.
- Clear and current CA Registered Nurse (RN) license.
Preferred Qualifications:
- 7 years UM experience with Charge/Lead/Supervisory/Management experience in Utilization Management department preferred.
- Experience working with health plan auditors preferred.
- Bachelors of Science in Nursing and/or Master's level degree preferred
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