Job Summary:
Develops, manages and directs the Utilization Management programs in a Service Area or a Medical Center. Develops and manages programs that emphasize appropriate admissions as well as concurrent and retrospective review of care. May also be responsible for other integrated functions such as Discharge Planning, Case Management program, Outside Utilization Review program, Transportation coordination and Extended Care Coordination to promote a centralized, coordinated, interdisciplinary process in the continuum of care.

Essential Responsibilities:

Provides overall direction, design, development implementation and monitoring of utilization programs to meet the Service Areas or Medical Centers utilization goals while maintaining customer satisfaction.

Acts as a resource to the medical staff, administrative staff, divisional, SCPMG, TPMG and external regulatory agencies in all issues relating to utilization management within the Service Area or Medical Center.

Oversees outside medical services based on Health Plan benefit guidelines and medical necessity.

Analyzes and reports significant utilization trends, patterns, and impact to appropriate departmental and medical staff committees.

May direct the operations of outside referrals/transportation services.

May serve as contract liaison for the Service Area or Medical Center on issues pertaining to new or existing contracts with outside vendors.

Develops, monitors and controls departments budgets.

Assures compliance with Federal, State, TJC, NCQA, other regulatory agencies and internal standards and requirements.

Hires, coaches, trains and disciplines staff to ensure smooth operations in utilization management.

Also facilitates educational training for medical staff on issues related to utilization management.

Basic Qualifications: Experience

Minimum three (3) years of experience in directing utilization management and discharge planning in an acute care setting.

Education

BSN or bachelors degree in healthcare related field such as management, health services administration.

License, Certification, Registration

Registered Nurse License (California)

Additional Requirements:

Demonstrated knowledge of operations and healthcare management; TJC, Title XXII, Medicare, Medi-Cal and other local, state and federal regulations.
Knowledge of managed care operations.
Demonstrated interpersonal, negotiation, and leadership skills.
Effective oral and written communication skills.
Must be able to work in a Labor/Management Partnership environment.

Preferred Qualifications:

Masters degree in a related field such as nursing, business or health services administration preferred.