Supervisor,Utilization Management; Clinical Job San Jose area,California USA,Management

Position: Supervisor, Utilization Management (Clinical)

FLSA Status:
Exempt
Department:
Health Services
Reports To:
Manager, Utilization Management

GENERAL DESCRIPTION OF POSITION

The Supervisor of Utilization Management (UM) is responsible for the direct oversight of daily operations of utilization management activities, providing assistance with the development and implement of new programs and related workflows, policies, procedures for all lines of business, and serving as a resource for internal departments, members, providers, delegates, and community partners. In addition, the Supervisor of UM is responsible for supervising nurses and coordinators to ensure that all administrative UM processes are performed in accordance with all applicable state and federal regulatory requirements, SCFHP policies and procedures and business requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Collaborate with the Manager of Utilization Management to implement and supervise all UM processes for continuous and sustained compliance with all applicable state, federal and NCQA regulatory requirements, SCFHP policies and procedures and general business requirements including key performance indicators of MCAS, HEDIS, and CMS Stars for all lines of business.

Monitor and provide continuous analysis and quality monitoring of all policies and procedures to evaluate UM staff and delegate performance and ensure regulatory compliance, including the development and implementation of effective, measurable corrective action plans to meet targeted strategic outcomes.

Ensure the integration of UM operations such as prior authorization, concurrent review, Transitional Care Services (TCS), and discharge planning into other internal and external teams/departments including Quality & Process Improvement, Case Management, Community Based Programs, Pharmacy, and Behavioral Health.

Perform oversight and assignment of caseload across various utilization management functions including routine and ad hoc audits and monitoring of corrective action plans.

Establish and maintain effective interpersonal relationships with all SCFHP staff, members and/or their authorized representatives, providers and other program or agency representatives.

Resolve or facilitate resolution of problematic and/or complex issues by escalating to appropriate management/leadership person.

Ensure Utilization Management Committee preparedness.

Attend off‑site meetings, events, or facility census review as necessary.

Perform other related duties as required or assigned.

SUPERVISORY/MANAGEMENT RESPONSIBILITIES

Recruiting, interviewing, and hiring.

Developing a high performing department culture and staff. This includes setting the standard for staff/peers and motivating employees to maximize organizational goals and objectives.

Effectively assimilating, training and mentoring staff and (when appropriate), cross training existing staff and initiating retraining. This includes coaching to help increase skills, knowledge and (if applicable) improve performance.

Setting goals and planning, assigning, and directing work consistent with said goals. This includes responding to employees’ needs, ensuring they have the necessary resources to do their work.

Appraising performance, rewarding and disciplining employees, addressing complaints and resolving issues. This includes providing regular and effective feedback to employees and completing timely and objective performance reviews.

REQUIREMENTS – Required (R) Desired (D)

Unrestricted professional RN licensure in the state of California. (R)
Minimum two years of progressively responsible experience in a supervisory or lead capacity in case management, utilization management, discharge planning and/or quality improvement in a managed care related setting. (R)
Understanding and/or experience with Utilization Management. (R)
Must be knowledgeable of DHCS, CMS, DMHC regulations and NCQA Population Health Management standards. (R)
Ability to consistently meet accuracy and timeline requirements to maintain regulatory requirements.
Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case…


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Job Posting Language

Supervisor, Utilization Management; Clinical