Manager - Utilization Management Manager

Community Health Group; Chula Vista (CA); On-site; USD 90,000 - 130,000; Full time

Job summary

Community Health Group seeks an experienced Utilization Management Manager to oversee inpatient and outpatient case management, transition of care, and health home programs. You will supervise UM/UR staff, coordinate care across the continuum, and ensure compliance with CMS and SNP regulations while driving quality improvement initiatives.

The role emphasizes staff development, policy implementation, and collaboration with interdisciplinary teams to optimize member outcomes and resource use in a

Qualifications

• 3 years of clinical nursing experience.
• 2 years of UM/UR experience.
• 2 years of managed care experience preferred.
• Familiar with CPT and ICD-10-CM coding; M&R criteria.

Responsibilities

• Supervise case managers and concurrent review nurses.
• Coordinate care across the continuum for a targeted client population.
• Develop, implement, and evaluate knowledge base for team.
• Ensure compliance with CMS, Medicare Part D, SNP and CHG policies.
• Prepare regulatory reports and attend committee meetings.

Skills

Clinical nursing

UM/UR experience

Managed care knowledge

Communication skills

Analytical

Education

BS in Nursing

MSN preferred

Tools

Microsoft Office

Job description

POSITION SUMMARY:The Utilization Management Manager orients, guides and oversees the Inpatient, Outpatient case managers, transition of care coordinator, Health Home Program (HHP), and Inpatient support staff. The role is to plan, develop, implement, evaluate and refine case management intervention. This individual supervises the case management and concurrent review personnel and ensures that they assess, plan and deliver care appropriate to the age specifics of every member and all others involved within the job structure.COMPLIANCE WITH REGULATIONSWorks closely with all departments necessary to ensure that the processes, programs, and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D and Special Needs Plan (SNP).RESPONSIBILITIESSupervises the case managers and concurrent review nurses in the performance of their role and position description.Assists the case managers in the coordination of care and service of a selected client population across the continuum of illness.Formulates, implements, and evaluates the knowledge base of the case managers and concurrent review nurses in the performance of their position description.Analyzes the case management goals for the members, reviews the plan for its appropriateness, and reviews and identifies anticipated outcomes.Develops and maintains a positive work climate that supports the overall staff efforts at CHG.Assists in developing the philosophy, goals, and objectives for concurrent case management performance that meets clinical and financial requirements.Anticipates, recommends, implements, and evaluates policies and procedures related to case management and concurrent review.Contributes to the organization’s goals and objectives; supports the organizational strategic plan.Actively participates in the development of clinician guidelines and incorporates the process into the role of the case managers.Interfaces with external agencies and provides appropriate information, consultation, and recommendations.Supports the culture of continuous quality improvement.Uses quality improvement tools and strategies in problem-solving activities.Identifies patterns or trends in case management that have or had the potential for adverse impact on member interventions.Develops corrective action plans and reevaluation of outcomes.Attends educational and training programs to expand knowledge.Prepares all regulatory reports in a timely manner.Attends all committee meetings along with ensuring meeting minutes are correct and detailed.Works on all assigned projects as requested. All other duties as assigned.EDUCATIONBS in NursingMasters in Nursing preferred.Foreign medical graduates, health education, or another mental/social health discipline (a combination of experience and education will be considered in lieu of a degree in nursing).EXPERIENCE/SKILLS3 years of clinical nursing; 2 years of UM/UR experience2 years of experience in managed care is preferred.CPT and ICD10-CM coding; M&R and/or other UM criteria; Microsoft Office software or equivalent; knowledge of applicable state and federal laws and NCQA; working knowledge of Medicaid, CCS required.Experience in interpreting Utilization and benefits data.Strong communication skills; analytical; ability to organize work effectively, determine priorities; works well independently and as a team player.Skilled and proficient in applying highly technical principles and concepts.Demonstrated ability to interact with a wide variety of individuals and to handle complex situations simultaneously.PHYSICAL REQUIREMENTSUtilizing computers over prolonged periods of time.Must maintain confidentiality; may be necessary to work and attend meetings outside facility or normal business hours; may be required to work evenings and weekends.The above statements describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.All qualified applicants will receive consideration for employment based on merit, without regard to race, color, religion, sex, national origin, disability, protected Veteran Status, or any other characteristic protected by applicable federal, state, or local law.