Nursing
Manager - Utilization Management, Outside Services
Employee Type :
Full-Time
Industry :
Healthcare - Health Services
Manages Others :
No
Job Type :
Health Care
Management
Nurse
Experience :
Not Specified
Relocation Covered :
No
Post Date :
2/9/2012
Contact InformationRef ID :
102576
Description
Manager / Utilization Management / Outside Services/ UM / DP
(Job Number: 102576)
At Kaiser Permanente Northern California, you’ll join a team of health advocates who share your passion for helping people. From our financial professionals and IT team members to our RNs and physicians on the front line of care—we work together to help our members achieve their best level of wellness. And you’ll be inspired to do the same. Whether you dream of sailing the bay, hitting the slopes in the Sierras, hiking Yosemite, attending the opera, or strolling the vineyards, you’ll discover the cultural and recreational diversity that makes Northern California one of the most desirable places in the world to live and work. Northern California’s largest health plan, Kaiser Permanente provides you with the resources, scope, and opportunity you need to realize your goals. Come see for yourself.
Description
This position develops, coordinates, & manages the administrative & operational activities that are directly associated w/ the utilization management of medical services provided to Kaiser's members. In addition, it works independently & establishes priorities for staff.
Essential Functions:
• Chairs & Co-chairs local committees focused on creating, implementing & monitoring work plans to achieve UM targets & performance improvement
• Shares accountability w/ other medical center leadership for the daily monitoring of utilization indicators & performance, identification & escalation of problems, & initiation & evaluation of action plans for achieving medical center targets & improve the quality of care & services
• Participates & provides UM expertise on local & regional committees, including UM Peer, UM Chiefs/Directors, Quality, TPMG, other departments & contracted/planned providers
• Manages projects related to chart reviews & conducts utilization data analysis (avoidable days, readmissions, UMAB, PRS reports, one-day stays, DRG's, LOS, PDR's, etc.) for trending & development of performance improvement initiatives
• Partners w/ the UM Chief & KFH/TPMG local medical center leadership, to engage the following areas in the development & implementation of a comprehensive utilization management, work plan to meet or exceed medical center targets
• Identifies & incorporates (as appropriate) evidence-based best/successful practices (e.g. care paths, innovative discharge planning/case management models, etc) into efforts to improve quality of care/service & reduce costs
• Collaborates w/ interdisciplinary teams across the continuum of care including, but not limited to (HBS, TPMG Sub-specialty departments, Nursing, MSW, PT/OT, HH, Hospice, SNF, CCM, Behavioral Health, Rehabilitation, etc.) to ensure patient care is effectively provided, clinically appropriate, service oriented, safe & cost effective
• Ensures compliance w/ regulatory/accreditation (NCQA, MDQR, CMS, Medical, DMHC, DOL, The Joint Commission, etc.) requirements related to UM by partnering w/ other departments & facilitating workgroups in maintaining survey readiness
• Directs staff review of the UM related aspects of treatment & discharge plans (Case Managers, Discharge Planners, Patient Care Coordinators, etc.) to ensure high quality & cost-effective discharge planning
• Supports UM staff in negotiating barriers or systems issues to expedite patient services during the hospital stay
• Accountable for oversight of UM activities (e.g., the appropriate use of InterQual, other criteria/guidelines), MIDAS, & the denial process
• May be responsible for claims management, repatriation, & ambulance
• May be responsible for oversight of coordination of care in planned & contract hospitals/providers
• Consultation & collaboration w/ TPMG/KFH Medical Center leadership to ensure discharge-planning activities are HR related activities
• Manages & resolves human resource, employee, department safety, & risk management issues
• Responsible for all aspects of staff management including, hiring, development/training, performance reviews, & terminations integrated into the broader service area utilization management initiatives
• Manages department budget & finances & develops, implements, & monitors departmental policies & procedures
Secondary Functions:
• Position will lead operational work case managing outside claims and referrals.
• Position will develop and lead multi-dimensional performance improvement program to reduce overall costs, and enhance service and quality for our patients and members in external hospitals.
• Position will primarily be located in downtown Modesto. May include some travel witin the service area.
• May be asked to provide coverage at other KFH facility in CVA depending on needs.
Qualifications
Basic Qualifications:
• A minimum of 3 years of experience in management /leadership in a hospital or outpatient setting
• A minimum of 3 years of experience in utilization management activities required
• BSN or BA in health care related field or equivalent experience required
• Graduate of accredited school of nursing
• Master's degree preferred
• Current California RN licensure
• Knowledge of the Nurse Practice Act, The Joint Commission, NCQA, and other local, state, and federal regulations
• Demonstrated skills in leading and facilitating the efforts of multidisciplinary groups
• Demonstrated strong communication, problem-solving and analytical skills
Preferred Qualifications:
• Strong people skills and case management experience
• Strong background in project management and performance improvement with demonstrated accomplishments in large systems to enhance efficiency, cost effectiveness, service and quality
Primary Location: California-Modesto-Modesto 16th St. Administration 920 - 16th St. St
Scheduled Hours (1-40): 40
Shift: Day
Working Days: Mon - Fri
Working Hours Start: 8:00am
Working Hours End: 5:00pm
Schedule: Full-time
Job Type: Standard
Employee Status: Regular
Employee Group: Salaried Employees
Job Level: Manager with Direct Reports
Job: QA / UR / Case Management
Public Department Name: Continuity of Care / Utilization Management / DP
Travel: No
Job Eligible for Benefits: Yes
External hires must pass a background check/drug screen. We are proud to be an equal opportunity/affirmative action employer.
Find Manager - Utilization Management, Outside Services Salary Information >>