Director of Utilization Management
Our Mission.. Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system.
Under administrative direction of the Senior Director of Health Services and medical direction from the Chief Medical Officer (CMO), this position maintains accountability for medical management functions to achieve the business and clinical outcomes, meeting contract requirements, NCQA accreditation standards (if applicable), and supporting initiatives with providers and members to manage cost of care. The functions overseen by the Director include utilization management and criteria-based reviews of care, clinical appeals regarding medical necessity, and the interaction with claims payment policies and processes.
This position is responsible for the Utilization Management (UM) functions of Kern Health Systems (KHS). The Director of UM will provide direction to the UM Clinical and Non Clinical Staff, ensuring that the appropriate level of member care is being provided.
In collaboration with the Senior Director of Health Services, assists in coordinating UM functions and programs which effectuate and support KHS medical policy according to contractual requirements, and in developing and implementing new clinical programs to manage costs and ensure quality care delivery.
- Maintains overall responsibility for staff coverage and assignments related to Precertification/Authorization, Concurrent Review, Discharge planning, and special services activities.
- Serves in a supportive role as a member of the Physician’s Advisory, Quality Improvement and Utilization Management, and Pharmacy & Therapeutics Committees.
- Provides direction and acts as resource to UM department staff in terms of contract and benefit clarifications.
- Evaluates staff performance with input from departmental Supervisors and Manager.
- Makes recommendations for changes to work processes in order to streamline department functions as needed.
- Overall responsibility for direction for, Clinical and Non-Clinical Intake Staff, and UM nurses.
- Ensures compliance with UM standards as outlined in DHCS contract for UM functions; i.e. turnaround times, provider and member notifications, appeals, retrospective review, etc.
- Serves as a Management clinical representative at both internal and external meetings as needed.
- Responsible for detailed utilization analysis and benchmarking.
- Works closely with Health Services Program Administrator and the UM clinical analyst team in developing new UM reporting templates for the department.
- Encourages cross-departmental communications and participation in project initiatives
- Works collaboratively with the claims department to ensure authorization and claims matching process through accurate documentation in both the Core claims system and the Medical Management Program
- Facilitates information sharing and problem resolution by establishing cooperative relationships with KHS departments and staff, contracted providers, regulatory agencies, and local community partners
- Assists in determining staffing ratios within departmental budgets and developing departmental budget.
- Encourages staff in growth opportunities, in-services, seminars, etc.
- Directs, coordinates and evaluates efficiency and productivity of utilization management functions for physical and behavioral health services (mental health and applied behavioral analysis).
- Works closely with pharmacy and vendors to assure integration, oversight, and efficiency of UM and appeals processes and for delegated functions.
- Develops a comprehensive orientation program for all new employees in the Health Services Department.
- Assists in the continuous development, implementation, and improvement of the KHS Utilization Management programs for Inpatient Concurrent Review and Outpatient referrals and coordination of services.
- Establishes and monitors a after-hours clinical triage programs to provide assistance to members in obtaining appropriate medical care outside standard office hours.
- Prepares reports, including analysis, of UM activities and statistics for review and evaluation by management
- Collaborates with network leaders to design and operationalize successful methods for working with hospitals, home health, and other ancillary services.
- Assist the CMO, Medical Directors, and Senior Director of Health Services in the development and review of UM medical criteria for reference by case management staff.
- Assist in the review and updating of Policy and Procedures related to UM.
- Demonstrated competence in application of evidence based criteria in the utilization processes for determining medical necessity
- Ensures seamless coordination of referral processing between Utilization Management and Pharmacy.
- Assists in Complex Case Management support of emergent referral services.
- Coordinates with Health Services leadership in identifying inappropriate utilization of services among members.
- Coordinates with Provider Relations staff on referral and inpatient activity where provider behavior needs to be addressed or provider feedback/input is required.
- Reviews and approves Notice of Action (NOA) letters and Letters of Agreement (LOA) for non-contracted providers and facilities, ensuring appropriate alternatives have been considered for contracted services.
- Evaluates, assesses, coordinates, and initiates processes towards NCQA accreditation in the areas of Utilization Management.
- Interviews, selects, trains, develop, and evaluate staff; provides input to management regarding disciplinary issues, including Performance Improvement Plans (PIP).
- Performs other job-related duties as required.
- Adheres to all company policies and procedures relative to employment and job responsibilities.
CORE COMPENTENCIES / KNOWLEDGE & SKILL REQUIREMENTS
- Strong knowledge of the principles, techniques and practice of public and community health education, including the understanding of the theory and ability to apply knowledge of the basis of human behavior, the process of education, motivation and group work, and the relationships of cultural patters of human behavior;
- Demonstrated knowledge of and skill in protocols of Disease Management;
- Strong knowledge of common patient disease processes and usual methods of treating them;
- Knowledge of medical terminology and commonly used equipment;
- Knowledge of ICD9 and/or CPT coding;
- Ability to supervise and mentor staff, analyze situations independently and make appropriate decisions;
- Ability to prepare written reports and maintain accurate records;(E)
- Strong analytical, assessment and problem-solving skills with intermediate negotiation skills;
- Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individuals at all levels both inside and outside of KHS;
- Ability to use tact and diplomacy to diffuse emotional situations;
- Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards;
- Advanced computer skills that include MS Office products ;
- Demonstrated ability to commit to and facilitate an atmosphere of collaboration and team work;
- Demonstrate ability to respect and maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to, patient healthcare, KHS business or employee information and make no disclosure of such information except as required in the conduct of business.
- Demonstrated ability to multi-task in an interrupt-driven environment and complete assignments on a timely basis;
- Strong attention to detail; work accurately and at a reasonable rate of speed;
Education: Possession of a valid California R.N. license required; completion of a Bachelor’s Degree from an accredited college or University in Nursing (BSN) or other relevant health care field required.
Experience: Five (5) years of management level experience in Utilization Management and in a managed care environment AND one (1) year of experience as a Utilization Review Nurse or Medical Case Manager;
Three (3) years of experience as a Utilization Review Nurse or Medical Case Manager AND two (2) years of management level experience in a Health maintenance organization (HMO) REQUIRED. Quality Improvement experience is highly desirable.
Knowledge of: Utilization Management in a managed care environment; basic procedures utilized in claims processing in a managed care environment; medical reimbursement methodologies; supervisory and training techniques.
Ability to: Adapt to a rapidly evolving work environment; work independently and manage multi-task responsibilities; communicate with a variety of personnel and providers; establish and maintain appropriate quality improvement and utilization management programs; make decisions within a managed care environment; prepare a variety of statistical and narrative reports; effectively supervise and train staff.
Other: Possession of valid driver’s license and proof of State required auto liability insurance. Required Travel Up to 20%
- Pay Type Salary
- Travel Required Yes
- Travel % 20
- Telecommute % 0
- Required Education Bachelor’s Degree
- Kern Family Health Care, 2900 Buck Owens Blvd., Bakersfield, California, United States of America