UCSD Layoff from Career Appointment: Apply by 11/15/2017 for consideration with preference for rehire. All layoff applicants should contact their Employment Advisor. Eligible Disability Counseling and Consulting services (DCC) or Special Selection clients should contact their Vocational Rehabilitation Counselor for assistance.
This position will remain open until a successful candidate has been identified.
The Utilization Program Manager oversees Case Managers and Clinical Referral Coordinators. Manages day to day operations of the department. Utilizes clinical expertise and understanding of utilization review requirements, discharge planning process, and health plan guidelines. Assists with hiring, evaluating and supervises performance of the Case Management staff, evaluates caseloads, and if necessary makes daily assignments. Evaluates and addresses educational needs of the staff, conducts performance improvement management and issues corrective action as needed, ensures consistent applications of policies and compliance. Assists in development and maintaining department policies for utilization review consistent with contractual obligations. Establishes relationships with primary care and specialty providers and collaborates with key physician and administrative leaders.
Other Key Responsibilities
Supervises staff responsible for case management, to include all or most of the following: utilization management, discharge planning, social work services, denial management, and patient throughput.
Oversees and coordinates department operations, schedules staff to ensure adequate coverage, resolves system issues, advises on work methods, functions as a resource and assists with complex cases and escalated issues.
Coordinates and / or leads case management teams with a variety of clinical and nonclinical staff to review specific cases, develop alternative treatment plans, and evaluate options for quality and efficiency along the full continuum of care.
Collects, analyzes, and reports data on case management processes and results, including quality of patient care, clinical and social-service outcomes, discharge planning, referrals, cost and utilization data, resource management, and regulatory compliance.
Collaborates with management on operational and performance issues and the development of new plans and programs to improve case management systems and processes across the spectrum of care coordination services.
Evaluates subordinate staff and participates in decision-making on hiring, salary actions, terminations, performance ratings, and other human resources matters.
Pursues professional development and facilitates access to ongoing training, staff development, and educational opportunities for subordinate staff.
Ensures adequate orientation, training, and mentoring of new staff.
Keeps staff and patient care teams informed of changes and updates in processes, technology, regulations, and quality standards.
Implements new methods, systems, and processes.
Oversees all aspects of the annual audit process with the health plans.
Other duties as assigned.
Bachelor's degree in nursing (BSN) or equivalent combination of experience / training.
RN license issued by the State of California.
Must have 5 or more years of relevant RN experience in an acute care or clinical setting.
Background in case management, utilization review and discharge planning, or homecare or managed care.
Previous Supervisory/Management experience.
General knowledge of payer industry, resource management, reimbursement, and evidence-based clinical practice is essential.
Must possess strong interpersonal skills, leadership, negotiation skills, good leadership talent, and knowledge of hospital operations.
Skilled in conflict management and resolution.
Proficiency in Information Systems and computer programs such as Word, Excel, etc.
ACM and/or CCM certificate.
EPIC, Milliman, ECIN experience.
Must be able to work various hours and locations based on business needs.
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