Develops, coordinates and manages the administrative and operational activities that are directly associated with the utilization management of medical services provided to the company's members. Works independently; establishes priorities for staff.
Chairs and Co-chairs local committees focused on creating, implementing and monitoring work plans to achieve UM targets and performance improvement. Provides expertise into target setting processes. Shares accountability with other medical center leadership for the daily monitoring of utilization indicators and performance, identification and escalation of problems, and initiation and evaluation of action plans for achieving medical center targets and improve the quality of care and services. Participates and provides UM expertise on local and regional committees, including UM Peer, UM Chiefs/Directors, Quality, TPMG, other departments and contracted/planned providers. Manages projects related to chart reviews.
Conducts utilization data analysis (avoidable days, readmissions, UMAB, PRS reports, one-day stays, DRGs, LOS, PDRs, etc.) for trending and development of performance improvement initiatives. Partners with the UM Chief and KFH/TPMG local medical center leadership, to engage the following areas in the development and implementation of a comprehensive utilization management work plan to meet or exceed medical center targets: Physicians, managers across the continuum, and TPMG/KFH service leaders and managers. May include oversight of the coordination of KP members' care with leaders responsible for UM activities associated with alliance/contract hospitals and networks.
Links with the Quality Department to ensure quality improvement, risk, and safety management activities are aligned with local UM initiatives.
Identifies and incorporates (as appropriate) evidence-based best/successful practices (e.g. care paths, innovative discharge planning / case management models, etc.) into efforts to improve quality of care/service and reduce costs.
Collaborates with interdisciplinary teams across the continuum of care including, but not limited to (HBS, TPMG Sub-specialty departments, Nursing, MSW, PT/OT, HH, Hospice, SNF, CCM, Behavioral Health, Rehabilitation, etc.). to ensure patient care is effectively provided, clinically appropriate, service oriented, safe and cost effective. Partners with TPMG to provide UM related education and training as needed.
Ensures compliance with regulatory/accreditation (NCQA, MDQR, CMS, Medi-Cal, DMHC, DOL, JCAHO,etc.) requirements related to UM by partnering with other departments and facilitating workgroups in maintaining survey readiness.
HR related activities (average 18 employees): Manages and resolves human resource, employee, department safety, and risk management issues. Responsible for all aspects of staff management including, hiring, development/training, performance reviews and terminations.
Manages department budget and finances. Develops implements, and monitors departmental policies and procedures.
Three (3) or more years of experience in management /leadership in a hospital or outpatient setting.
Minimum three (3) years of previous experience in utilization management activities required.
Graduate of accredited school of nursing.
BSN or BA in healthcare related field OR four (4) years of experience in a directly related field required.
Current California RN licensure.
Knowledge of the Nurse Practice Act, JCAHO, NCQA, and other local, state, and federal regulations.
Demonstrated skills in leading and facilitating the efforts of multidisciplinary groups.
Demonstrated strong communication, problem-solving and analytical skills.
Must be able to work in a Labor/Management Partnership environment.