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RN Utilization Management Nurse Manager
Torrance, CATemp To Hire Position
A workweek in excess of 40 hours may be required from time to time.
SUMMARY:
Under the direction of the Chief Medical Officer (CMO), the Utilization Management (UM) Manager works closely with the CMO and various departments to establish department clinical goals and compliance. The UM Manager is responsible to oversee the operational aspects of the UM Department while maximizing efficiency of the UM department with consistent processes and identification of operational issues including systems issues to be addressed. Evaluates medical necessity, appropriateness, and efficiency of medical services for THIPA members while following insurance guidelines. Employee works closely with physicians, hospitals, and health plans along with internal departments concerning utilization review.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
• Oversees compliance guidelines with local, state, federal, and private agencies
• Establishes, maintains, and achieves department goals that are aligned with THIPA initiatives, including but not limited to UM turn-around times
• Oversees and directs staff to ensure established performance standards are met
• Following insurance guidelines, evaluates the necessity, appropriateness, and efficiency of medical services and procedures provided to THIPA members
• Coordinates cost effective care supported by clinical practice guidelines
• Accurately and comprehensively Documents UM decisions based on the standards of practice and current THIPA policies
• Effectively provides feedback to provider(s) concerning necessary documentation to meet reimbursement requirements
• Acts as a resource for medical and ancillary staff in issues relating to the UM department
• Telephonically interacts and communicates with multidisciplinary teams, striving for continuity of care for our members
• Understands fiscal accountability and its impact on the utilization of resources
• Identifies effects of under-utilization, as well as over-utilization of services
• Develops and/or updates the Utilization Management department policies and procedures
• Uses, protects, and discloses member’s PHI only in accordance with HIPAA standards
• Assists Human Resoures in recruiting, retaining talented staff, and monitoring staff performance.
• Supports department initiatives
SUPERVISORY RESPONSIBILITIES
This position supervises the UM support staff of eight. This position carries out responsibility in accordance with THIPA policies and procedures, and applicable laws. Responsibilities include interviewing, training, planning, assigning, and directing work; appraising performance; regarding disciplining employees, addressing complaints, and resolving complaints.
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
SKILLS/KNOWLEDGES/ABILITIES:
• Thorough knowledge of utilization management
• The ability to establish and maintain professional relationships and communication with a wide variety of people and to work as a team member.
• High multi-tasking skills with the ability to set appropriate priorities
• Demonstrated high degree of personal integrity, loyalty to the organization, precision, and attention to detail
• Contributes ideas for improving efficiency, productivity, and patient satisfaction
• Ability to maintain confidentiality of all patient information
• Excellent delegating and communication skills
• Ability to lead and direct staff
EDUCATION and/or EXPERIENCE:
• Graduate from an accredited school of nursing
• Undergraduate degree preferred
• Current, unrestricted California RN license
• Minimum three years management level experience
LANGUAGE SKILLS:
Good command of the English language. Ability to read and understand complex insurance contracts.
MATHEMATICAL SKILLS:
Basic math skills required. The ability to multiply and divide is required.
CERTIFICATIONS, LICENSES, REGISTRATIONS:
Registered Nurse in the State of California required.
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essentials functions.
While performing the duties of this job, the employee might spend up to 10% of the time standing, stooping, or walking. The employee will sit the remaining time. The employee will be required to sit; walk, climb stairs, kneel down; use hands, to finger, handle, or feel; and reach with hands and arms. Specific vision abilities required by this job include close vision, color vision, and the ability to adjust focus.
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The work environment for this position includes an office space. This work area is clean and comfortable. It may include minor annoyances such as noise, and drafts.
REQUIRED / DESIRED SKILLS
CA RN License
AHA-BLS
Management Level Experience
Travel Experience
Graduate from an accredited school of nursing
Undergraduate agree - Highly Desired
A workweek in excess of 40 hours may be required from time to time.
SUMMARY:
Under the direction of the Chief Medical Officer (CMO), the Utilization Management (UM) Manager works closely with the CMO and various departments to establish department clinical goals and compliance. The UM Manager is responsible to oversee the operational aspects of the UM Department while maximizing efficiency of the UM department with consistent processes and identification of operational issues including systems issues to be addressed. Evaluates medical necessity, appropriateness, and efficiency of medical services for THIPA members while following insurance guidelines. Employee works closely with physicians, hospitals, and health plans along with internal departments concerning utilization review.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
• Oversees compliance guidelines with local, state, federal, and private agencies
• Establishes, maintains, and achieves department goals that are aligned with THIPA initiatives, including but not limited to UM turn-around times
• Oversees and directs staff to ensure established performance standards are met
• Following insurance guidelines, evaluates the necessity, appropriateness, and efficiency of medical services and procedures provided to THIPA members
• Coordinates cost effective care supported by clinical practice guidelines
• Accurately and comprehensively Documents UM decisions based on the standards of practice and current THIPA policies
• Effectively provides feedback to provider(s) concerning necessary documentation to meet reimbursement requirements
• Acts as a resource for medical and ancillary staff in issues relating to the UM department
• Telephonically interacts and communicates with multidisciplinary teams, striving for continuity of care for our members
• Understands fiscal accountability and its impact on the utilization of resources
• Identifies effects of under-utilization, as well as over-utilization of services
• Develops and/or updates the Utilization Management department policies and procedures
• Uses, protects, and discloses member’s PHI only in accordance with HIPAA standards
• Assists Human Resoures in recruiting, retaining talented staff, and monitoring staff performance.
• Supports department initiatives
SUPERVISORY RESPONSIBILITIES
This position supervises the UM support staff of eight. This position carries out responsibility in accordance with THIPA policies and procedures, and applicable laws. Responsibilities include interviewing, training, planning, assigning, and directing work; appraising performance; regarding disciplining employees, addressing complaints, and resolving complaints.
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
SKILLS/KNOWLEDGES/ABILITIES:
• Thorough knowledge of utilization management
• The ability to establish and maintain professional relationships and communication with a wide variety of people and to work as a team member.
• High multi-tasking skills with the ability to set appropriate priorities
• Demonstrated high degree of personal integrity, loyalty to the organization, precision, and attention to detail
• Contributes ideas for improving efficiency, productivity, and patient satisfaction
• Ability to maintain confidentiality of all patient information
• Excellent delegating and communication skills
• Ability to lead and direct staff
EDUCATION and/or EXPERIENCE:
• Graduate from an accredited school of nursing
• Undergraduate degree preferred
• Current, unrestricted California RN license
• Minimum three years management level experience
LANGUAGE SKILLS:
Good command of the English language. Ability to read and understand complex insurance contracts.
MATHEMATICAL SKILLS:
Basic math skills required. The ability to multiply and divide is required.
CERTIFICATIONS, LICENSES, REGISTRATIONS:
Registered Nurse in the State of California required.
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essentials functions.
While performing the duties of this job, the employee might spend up to 10% of the time standing, stooping, or walking. The employee will sit the remaining time. The employee will be required to sit; walk, climb stairs, kneel down; use hands, to finger, handle, or feel; and reach with hands and arms. Specific vision abilities required by this job include close vision, color vision, and the ability to adjust focus.
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The work environment for this position includes an office space. This work area is clean and comfortable. It may include minor annoyances such as noise, and drafts.
REQUIRED / DESIRED SKILLS
CA RN License
AHA-BLS
Management Level Experience
Travel Experience
Graduate from an accredited school of nursing
Undergraduate agree - Highly Desired