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Utilization Management (UM) Manager

Company: Palomar Health Medical Group
Location: Escondido
Posted on: March 18, 2023

Job Description:

Under the direction of the Director of Utilization/Case Management the Utilization Management (UM) Manager is responsible for managing all activities that surround Utilization Management and support to Case Management functions; monitoring of compliance related to claims and referrals/authorizations. The Utilization Management Manager orients, guides and monitors the needs of the UM/CM Case Managers, the inpatient and SNF Case Managers to ensure that they are supported in their activities. Extensive physician interaction to assure communication with PCP and specialty. Development of programs designed to manage case manager's quality and case review by providing all support including phone calls, internet research, accurate directories letters of agreement, etc. The role is to ensure that the UM/CM team has all the tools needed including criteria, assistance in locating vendors and specialists, working with SCMG, providing Desk Top Policies as needed, update to the UM/CM staff any new benefits and if contracts are needed. This individual supervises the case management and concurrent review personnel and ensures that they assess, plan, and deliver care appropriate to the age specifics of every member and to all others involved within the job structure. Assures that UM Case Managers are fully supported by providing resources to use during review. Follows health system rules, policies, procedures, applicable laws, and standards addressed in the Compliance Program. Responsible for carrying out the mission, vision, values, and commitment of Palomar Health Medical Group. Collaborate with Member Services Manager to coordinate any new guidelines related to new policies and procedures. Supports Member Services when the Member Services Manager is not available. Works closely with all PHMG departments necessary to ensure that the processes, programs, and services are accomplished in a timely and efficient manner in accordance with SCMG and PHMG policies and procedures.
Supervises the case managers and concurrent review nurses in the performance of their role and position description. Attends all meetings that involve UM and CM with both SCMG and PHMG related to policies and procedures and upcoming new ventures. Assists the case managers in the coordination of care when requested. Includes phone calls to specialists, office managers, patients, and physicians. Formulates, implements, and evaluates the knowledge base of the case managers and concurrent review nurses in the performance of their position description by advising them of SCMG policies and procedure including Desk Top Policies. Develops and maintains a positive work climate that supports the overall staff efforts in the UM/CM Department. Coordinates with Member Service Manager and collaborates on duties for both Member Services and UM/CM. Assists in managing Metric goals for the UM processes. Anticipates, recommends, implements, and evaluates policies and procedures related to case management and concurrent review. Contributes to the organization's goals and objectives; supports the organizational strategic plan. Interfaces with external agencies and provides appropriate information, consultation, and recommendations. Supports the culture of continuous quality improvement. Identifies patterns or trends in case management that have or had the potential for adverse impact on member interventions. Coordinates Peer-to-Per requests with communication to the appealer with criteria and information. Attends educational and training programs to expand knowledge. Works on assigned projects as requested and as the UM Director requests.
Oversight of all activities related to the utilization management/resources activities for PHMG along with the Director, including oversight of UR/Case Management, referrals and claims management, job descriptions, policies and procedures, yearly evaluation of staff. Monitoring and evaluation of all utilization/case management, referrals. Includes notification of any new criteria, policies and procedures directed by SCMG and any other new insurance plans accepted by PHMG. Attending meetings with Director and management of minutes. Will assist UM Director with hiring, monitoring and evaluations of staff needed to implement utilization/case management of all HMO activities. Will assume the responsibility of timecard management and vacation schedules for UM. Extensive physician interaction to include all primary care providers and specialists. Responsibilities include coordination of educational materials/training and communication of information. Responsible for presenting and recommending contracted vendors providing resource services to HMO members. Includes the oversight of cost and quality management. Supervision of Case Management Assistant including training and transitioning of day-to-day responsibilities: update of directory, developing reports of leakage of referrals, minutes management of UM Meeting. The following job duties may potentially be reassigned: Contacting vendors, providers, facilities to schedule services. Includes verification of eligibility, verification of benefits and follow-up of care provided. Customer Service: Job duties related to serving customers identified as Patients, Practitioners, Specialists, Vendors, other Graybill staff members: Telephone management: clear voice, cheerful/professional handling of the call, quick turnaround time in responses to the questions, etc. Accurate management of referrals to include correct data entry, correct Specialist, Provider entered, faxing to appropriate Specialist or Provider with letter generated to correct member, sent to correct address, and mailed within 2 business days. Appropriate appearance to reflect professionalism in the workplace, greet visitors with a professional appearance, Etc. Compliance: Duties and responsibilities to comply with Graybill Policies and Procedures and State, Federal and local regulations. Compliance with all HIPAA policies as outlined by the HIPAA coordinator. Compliance with all SCMG requirements for handling referrals as outlined in the SCMG manual. Compliance with Policies and Procedures in the Case Management Department.
Speak and read English at a level that is sufficient to satisfactorily perform the essential functions of the position. Knowledge of standard office equipment (i.e., calculator, fax, photocopier) and personal computer and computer software skills (i.e., MS Windows, Excel, Access, Word, PowerPoint, internet, e-mail). Windows computer skills including proficient use of keyboarding, use of mouse or keys for functions such as selecting items, use of drop-down menus, scroll bars, opening folders, copying and similar operations required upon employment or within the 1st two weeks of employment to perform the essential functions of the job. Performs other duties as assigned. Follows Palomar Health rules, policies, procedures, applicable laws, and standards. Carries out the mission, vision, and quality commitment of Palomar Health.

Job RequirementsMinimum Education: Bachelor's in Health Care Administration

Preferred Education: Bachelor's in Nursing

Minimum Experience: 2-3 years of UM/UR; CPT and ICD9-CM coding; M&R and/or other UM criteria, and working knowledge of Medicaid

Preferred Experience: 2 years in managed care

Required Certification: American Heart Association recognized BLS - Healthcare Provider
Certified Coding Specialist (CCS)

Preferred Certification: Not Applicable

Required License: Current CA RN License

Preferred License: Not Applicable

Keywords: Palomar Health Medical Group, Escondido , Utilization Management (UM) Manager, Executive , Escondido, California

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