Care Management/Utilization Management Director- Healthcare

CARE MANAGEMENT/UTILIZATION MANAGEMENT DIRECTOR

Hours: 8a-5p

Experience Requirements:

8 YEARS EXPERIENCE IN-PATIENT CARE AND 5 YEARS PROGRESSIVE MANAGEMENT EXPERIENCE.

DEMONSTRATED KNOWLEDGE OF KNOX,KEENE ACT, FEDERAL HMO ACT, NURSE PRACTICE ACT, JCAHO, AND ALL OTHER LOCAL, STATE, AND FEDERAL REGULATIONS.

Demonstrated strong interpersonal communication skills.

Educational Requirements:

BSN OR BA IN HEALTH CARE RELATED FIELD REQUIRED.

CURRENT CALIFORNIA RN LICENSE REQUIRED.

BLS REQUIRED.

GRADUATE OF ACCREDITED SCHOOL OF NURSING.

Master's degree preferred.

SCOPE OF THE PROJECT:

MANAGE CASE WORKERS AND SOCIAL WORKERS.

Top skills needed to succeed in this position:

1) INFLUENCE, 2) REGULATORY OVERSIGHT, 3) DAILY OPERATIONAL MANAGEMENT

TOP DAILY RESPONSIBILITIES:

Length of stay, 2) Patient day rate, 3) Observation status oversight, 4) Coordination of case management, 5) Interaction with medical staff

Who will the contractor be reporting to? Chief Operating Officer
Will the contractor be managing anyone? Yes

TOP PERSONALITY CHARACTERISTICS:

1) Organized, 2) Relationship building, 3) Influence skills

Job Description:
Directs, plans, organizes, evaluates and coordinates operations of the Utilization/Resource Management Department focused on the achievement of satisfactory patient outcomes and has overall responsibility for the coordination of care services provided by the hospital. The position carries 24/7 operational responsibility. Provides oversight of the utilization management functions within the organization as directed by its policies and procedures and are aligned with federal, state and local regulations. Coordinates with TPMG and appropriate hospital staff to provide for the seamless transition of patients across the continuum of care. Represents Health Plan for Hospital operations.

Directs development and implementation of quality and utilization standards across the hospital to
ensure coordinated plans of treatment, customer focused delivery of services, and cost effective
utilization of necessary services. Ensures compliance with administrative, legal and regulatory
requirements of the Health Plan contract and governmental and accrediting agencies. Oversees the
development of department standards as identified by regulatory agencies, including The Joint
Commission, NCQA, CMS, DHS, DPHS, and DMHC. Maintains a state of continuous regulatory
readiness. Maintains oversight of the concurrent and retrospective inpatient reviews and appeal
process.

Collaborates with other Service Directors in identifying and implementing innovative models and best
practices, Develops services that achieve a high level of customer satisfaction. Utilizes research data to
implement clinical changes and the delivery of patient care and member services. Evaluates processes
and makes recommendations to improve resource management systems and patient care outcomes.

Participates in Executive Team's strategic planning forums. Utilizes data to support quality patient
outcomes and presents to Executive Team ongoing and reliable information about the treatment and
patient flow throughout all levels of care and providing expertise in utilization management, regulatory
compliance and coordination of care.

Directs through managers all activities within the Resource Management department including Social
Services. Responsible for efficient utilization of resources and develops processes to screen, interview,
hire, train, and maintain the competency of all department staff. Develops, implements, and monitors departmental policies and procedures which support and meet the organization's goals and business
objectives. Manages and resolves human resource, labor relations, employee, and department safety
and risk management issues.

Participates in region wide peer group and leadership activities to drive consistency of operations and
performance improvement. Develops and manages systems and relationships with outside vendors;
contract and quality oversight with external vendors.

Develops budget and resource allocations for areas of responsibility. Manages the financial
performance and identifies and implements appropriate strategies to reduce costs and improve quality
of care and services. Focuses on prevention/intervention and identification if issues/problems prior to
their impact on operations and patient care; recommends and develops new programs for specialized
patient populations to improve quality and effect improved utilization of services. Monitors utilization
indicators; identifies and escalates issues; and initiates and evaluates action plans for achieving the
area's goals/targets.

Utilizes Health Connect to evaluate the quality of care provided and to manage the clinical operations
and to monitor quality, appropriateness, and accuracy of Health Connect documentation by staff.
Maintains role specific Health Connect documentation by staff. Maintains role specific Health
Connect competencies.