TEST Senior Manager Outpatient UM

JOB DESCRIPTION

Senior Manager, Outpatient Utilization Management

TITLE:

July 21, 2022

DATE:

11

GRADE:

Senior Director, Health Care Services

REPORTS TO:

140 Utilization Management

DEPT.

$143,453.67 - $179,317.09 - $215,180.51

SALARY: EXEMPT

PRINCIPAL RESPONSIBILITIES:

The Senior Manager, Outpatient Utilization Management (UM) works under the direct supervision of the Director, Health Care Services. This position oversees the outpatient utilization management (UM) team focusing on utilization management and care coordination to assure integration of all Health Care Services department operations. The Senior Manager provides a leadership role in formulating long term strategic planning in alignment with organizational goals to maximize efficiency, productivity and performance for the OP UM Department. This position provides mentorship and employee development for key personnel in OP UM. The Senior Manager is responsible for policy, program development and implementation to assure quality care and cost effective services to members. The role involves making appropriate business decisions and working effectively with multiple stakeholders inside and outside of the Alliance on key departmental initiatives, using excellent verbal and written communication and relationship building skills. This position is responsible for management and supervision of the outpatient UM team and maintaining strong working internal and external relationships.

Principal responsibilities include:

• Develop/implement processes to align with organizational strategic goals, with particular focus on UM and Case Management (CM)

• Collaborate in building cross functional relationships with department leadership and management across the organization

• Provide guidance and tools to Supervisors and staff on implementation of organizational goals and day to day management of those goals

• Leadership development

• Develop/create staff level opportunities for growth

• Mentor staff in their daily duties to sharpen and advance their skills to support career growth

• Develop and oversee systems for outpatient authorizations, productivity metrics and meaningful management reports of both activities and outcomes. This includes analysis and reporting on utilization, health outcomes, care coordination and expenses with comparison to state and national standards and benchmarks.

• Conduct ongoing analysis that results in department changes to boost efficiency and effectiveness and align work processes with department goals and objectives.

• Provide leadership to the organization with preparation and maintenance of DHCS and DMHC requirements, and NCQA accreditation for the UM standards.

• Assure staff and department compliance with all regulatory, contractual and accreditation requirements and provide documentation for audits and reviews, including CMS, DHCS, DMHC, and NCQA.

• Review and update policies and procedures and assure consistency with regulations, contracts, Provider Manual, Evidence of Coverage, and other plan documentation. This is performed in conjunction with other managers and directors.

• Assist with preparation of the annual UM Program Description, Program Evaluation and Workplan, as well as other reports and presentations for internal and external departments and organizations as needed.

• Work in a collaborative manner across the organization to achieve department and overall organizational goals.

• Work with the Director, Health Care Services and Medical Directors to ensure appropriate clinical guidelines are developed and practiced

• Review outpatient and elective inpatient admission authorization requests to maintain quality standards.

• Actively participate in recruitment, selection, and training of staff. Develop and communicate staff performance plans. Conduct annual performance appraisals of direct reports. Implement corrective measures and discipline as necessary.

• Support and coordinate the day-to-day department activities by coaching and assisting the departmental leadership for both the clinical and non-clinical staff.

• Design process improvement activities with technological opportunities based on departmental trends to improve efficiency, productivity and performance for improved member outcomes

• Provide training, development, and continuing education to staff.

• Maintain professional and technical knowledge, providing subject matter expertise on all aspects of UM across the Alliance.

• Perform other duties and special projects as assigned.

ESSENTIAL FUNCTIONS OF THE JOB

• Applying clinical guidelines to the review of authorizations
• Advance business and technical knowledge to interact with leadership,stakeholders and vendors
• Ability to lead projects effectively through framework development, and tracking to completion in the required timeframes
• Leading and participating in internal and external committes and meetings
• Customer service through building and maintaining existing work relatipnships with key personnel throughout the organization and externally
• Developing and analyzing systems and processes to achieve quality and efficiency measures.
• Developing quantitative and qualitative management reports and analyzes data.
• Communicating effectively and efficiently internally and externally, building collaborative relationships to drive success.
• Leadership development for UM staff: Supervising and training of staff to include but not limited to team building, evaluations, corrective actions, and progressive discipline procedures.
• Writing, reporting, administration, and analysis.
• Developing verbal presentations.
• Leading and participating in internal and external committees and meetings.
• Complying with AAH's mission and values, Code of Conduct, all regulatory and contractual requirements, policies, procedures, and internal controls.

PHYSICAL REQUIREMENTS

• Constant and close visual work at desk or computer.
• Constant sitting and working at desk.
• Constant keyboard and/or mouse use.
• Extensive typing required.
• Frequent verbal and written communication with staff and other business associates by telephone, electronic communication methods, correspondence, or in person.
• Occasional travel between offices for meetings.
• Occasional lifting of folders and other objects weighing between 0 and 30 lbs.
• Frequent walking and standing.
• Occasional driving of automobiles and/or travel in vehicles.

EDUCATION OR TRAINING EQUIVALENT TO:

• BSN or MSN required.
• Registered Nurse license, active and unrestricted licensed in the State of California.
• Administrative Master's Degree preferred (MPA, MBA, MPH or other health care or finance related master's degree.)
• Have a cleared TB test prior to or within seven days of hire.
• Current CPR and first aid card prior to or within six months of hire is preferred.
• Certification in applicable area preferred

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• Minimum 8 years healthcare related experience
• Minimum 6 years working within the health care, managed care environment
• Minimum 5 years managerial experience in health care,

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• Knowledge of Medi-Cal and/or Department of Health Services and/or Medicare regulations and standards required.
• Ability to motivate, train, and supervise.
• Ability to make thoughtful, timely decisions and exercise sound judgment.
• Experience with planning, implementing, and evaluating clinical and disease prevention programs preferred.
• Knowledge of population-based community health assessment and interventions preferred.
• Ability to work effectively in a multidisciplinary approach in management.
• Ability to communicate effectively, both verbally and in writing.
• Experience in use of various computer systems software as well as Windows and current Microsoft Office suite.

07/21/22 - Created, Reviewed & Approved - ASw/ASc