Recognized as one of America's leading health care providers and not-for-profit health plans. Founded in 1945, their mission is to provide high-quality, affordable health care services and to improve the health of their members and the communities they serve. Currently serving 11.8 million members in eight states and the District of Columbia. Care for members and patients is focused on their total health and guided by their personal physicians, specialists and team of caregivers. Their expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the art care delivery and world-class chronic disease management.
Provides direction of operations by departments focused on the achievement of satisfactory patient outcomes including overall responsibility for the coordination of care services provided by the hospital or within the continuum of care. Responsible for coordinating with the medical group and appropriate staff to ensure a seamless transition of patients across the continuum of care. Oversees the utilization management functions across the region in accordance to policies and procedures as well as federal, state and local regulations.
- Directs, organizes, plans and coordinates the utilization/ resource management and social services process assuring that the organizational goals and objectives for KFH/P are met.
- Directs development and implementation of quality and utilization standards across the hospital to ensure coordinated plans of treatment, customer focused delivery of services, and cost effective utilization of necessary services. Ensures compliance with administrative, legal and regulatory requirements of the Health Plan contract and governmental and accrediting agencies. Oversees the development of department standards as identified by regulatory agencies, including The Joint Commission, NCQA, CMS, DHS, DPHS, and DMHC. Maintains a state of continuous regulatory readiness. Maintains oversight of the concurrent and retrospective inpatient reviews and appeal process.
- Collaborates with other Service Directors in identifying and implementing innovative models and best practices, Develops services that achieve a high level of customer satisfaction. Utilizes research data to implement clinical changes and the delivery of patient care and member services. Evaluates processes and makes recommendations to improve resource management systems and patient care outcomes.
- Participates in Executive Team's strategic planning forums. Utilizes data to support quality patient outcomes and presents to Executive Team ongoing and reliable information about the treatment and patient flow throughout all levels of care and providing expertise in utilization management, regulatory compliance and coordination of care.
- Directs through managers all activities within the Resource Management department including Social Services. Responsible for efficient utilization of resources and develops processes to screen, interview, hire, train, and maintain the competency of all department staff. Develops, implements, and monitors departmental policies and procedures which support and meet the organization's goals and business objectives. Manages and resolves human resource, labor relations, employee, and department safety and risk management issues.
- Participates in region wide peer group and leadership activities to drive consistency of operations and performance improvement. Develops and manages systems and relationships with outside vendors; contract and quality oversight with external vendors.
- Develops budget and resource allocations for areas of responsibility. Manages the financial performance and identifies and implements appropriate strategies to reduce costs and improve quality of care and services. Focuses on prevention/intervention and identification if issues/problems prior to their impact on operations and patient care; recommends and develops new programs for specialized patient populations to improve quality and effect improved utilization of services. Monitors utilization indicators; identifies and escalates issues; and initiates and evaluates action plans for achieving the area's goals/targets.
- Point person for escalating complex patient placement cases to local/regional leadership and assure stakeholders are updated on continuum resources, afterhours processes, strategic partners, etc.
- Document cases for case reviews and co-lead Care Without Delay educational sessions.
- Coordinate patient cases between PCCs, MDs, ED staff, and SNF HUB
- Work with Continuum Administrator and MD leaders to build/sustain relationships with vendor partners
- Regular reports to Area Manager regarding outcome metrics
- Minimum eight (8) years of experience in patient care.
- Minimum five (5) years of management experience.
License, Certification, Registration
- Bachelor's degree in health services, business administration, public health, nursing or related discipline required.
- Current California license required in any of the following clinical professions: Registered Nurse, Pharmacist, Clinical Social Worker, Physical Therapist, Occupational therapist, Speech Therapist or Dietitian.
- Demonstrated knowledge of Knox, Keene Act, Federal HMO Act, Nurse Practice Act, The Joint Commission, and all other local, state, and federal regulations.
- Demonstrated strong interpersonal communication skills.
- Must be able to work in a Labor/Management Partnership environment.
- Master's degree preferred.
Additional Preferred Qualifications:
- Emergency or Critical Care clinical experience
- Continuum and Utilization knowledge/management
- Knowledge of Community Resources and Alternative Levels of Care
- Proficiency in KPHC, Allscripts, and ability to learn new applications as needed
As an employee, you are eligible for benefits according to your full-time/part-time status and the number of hours scheduled to work per week. Benefits may vary based on your region, position, scheduled hours, and representation by collective bargaining or employee groups, but generally include:
- generous vacation, holiday, and sick leave
- medical care (including prescriptions), vision, mental health, & dental care
- disability and life insurance coverage
- educational opportunities and tuition reimbursement
- employee assistance programs
- health care, dependent care, and transit spending account options
- retirement plans