RN Supervisor UM Prior Auth

Commonspirit; Rancho Cordova (CA); Hybrid; USD 60,000 - 80,000; Full time

Job summary

Commonspirit recherche un Superviseur de Gestion d'Utilisation pour coordonner les services au sein des groupes médicaux. Ce rôle exige une solide expérience clinique et en gestion pour superviser les opérations de l'équipe tout en garantissant des protocoles réglementaires. Les candidats doivent être des infirmiers diplômés avec des compétences en leadership et communication.

Qualifications

• Cinq années d'expérience clinique requises.
• Expérience en gestion de l'utilisation de trois à cinq ans requise.

Responsibilities

• Coordonner les opérations quotidiennes de l'équipe de pré-autorisation.
• Assurer des réponses rapides et appropriées aux examens de référence.

Skills

Leadership

Clinical Acumen

Communication

Education

Graduate of an accredited school of nursing

Clear and current CA Registered Nurse (RN) license

Job description

2 months ago Be among the first 25 applicants

• This position is hybrid in-office/clinic (Rancho Cordova and Woodland) and work from home.*
  
  

*Responsibilities*

• This position is hybrid in-office/clinic (Rancho Cordova and Woodland) and work from home.*
  
  

Position Summary

Under the guidance and supervision of the department Manager/Director the Supervisor of Utilization Management is responsible and accountable for coordination of services for Mercy Medical Group and Woodland Clinic Medical Group through an interdisciplinary process that provides a clinical and financial approach through the continuum of care. Promotes the quality and cost effectiveness of medical care by ensuring department staff are applying clinical acumen and the appropriate application of policies and guidelines to Managed Care prior authorization referral requests. Under general supervision this position is responsible for coordinating the daily operations of the UM Pre-Authorization team in order to ensure requests are processed in a consistent and timely manner while observing regulatory guidelines.

Responsibilities May Include

• Responsible for day to day operations of the Pre-Authorization team to include timely response and appropriate evaluation of referral reviews correct selection of criteria accurate prep to the UM Physician reviewer when indicated timely verbal and written documentation and completion of the file
• Ensures adequate staffing and assignments and adjusts workflow as needed to meet department goals.
• Assists manager with performance activities to include monitoring coaching educating and providing feedback to team.
• Ensures UM Physicians are provided the relevant information needed to accurately review a referral. Fosters the relationship between the Pre-Authorization team and the Medical Director and Physician Reviewers.
• Tracks cost savings from activities over time to evaluate success of programs. Maintains or removes programs based on organization and department goals. Develops reports for leadership as required.
• Implements the Departments Policies and Procedures to remain in compliance with Regulatory Agencies (DMHC DHS CMS NCQA ICE)
• Supervises the use of established criteria sets (Medicare Guidelines InterQual Health Plan Benefit Interpretation Guidelines and Medical Management Policies and DHMF Utilization Management guidelines and protocols.
• Works with other staff and references ICE to regularly ensure that all required forms and resource manuals are current updated and in compliance with regulations.
• Coordinates completion of Peer InterRater on an annual basis and summarizes results for the UM Committee initiating actions as requested.
• Proactively supports the Pre-Authorization team department and Organization participates in all ad hoc meetings and prepares ad hoc reports.
  
  

*Qualifications*

Minimum Qualifications

• Five or more (5+) year's clinical experience required.
• Three to five (3-5) years Utilization Management experience required.
• One to three (1-3) years charge/lead/supervisory/management experience required. Ablility to demonstrate leadership and management skills.
• Graduate of an accredited school of nursing.
• Clear and current CA Registered Nurse (RN) license.
  
  

Preferred Qualifications

• 7 years UM experience with Charge/Lead/Supervisory/Management experience in Utilization Management department preferred.
• Experience working with health plan auditors preferred.
• Bachelors of Science in Nursing and/or Master's level degree preferred
  
  

*Overview*

Dignity Health Medical Foundation established in 1993 is a California nonprofit public benefit corporation with care centers throughout California. Dignity Health Medical Foundation is an affiliate of Dignity Health – one of the largest health systems in the nation - with hospitals and care centers in California Arizona and Nevada. Today Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers we provide increasing support and investment in the latest technologies finest physicians and state-of-the-art medical facilities. Our 130+ clinics across the state of California deliver high-quality patient-centric care with an emphasis on humankindness. Through affiliations with Dignity Health hospitals along with our joint ventures and partnerships we offer a robust state-of-the-art health care delivery system in the communities we serve .We strive to create purposeful work settings where staff can provide great care while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled qualities that are vital to maintaining excellence in care and service.

[One Community. One Mission. One California ](https://youtu.be/RrPuiSnALJY?si=pvQgPZ6ZWZM60TPV)

*Pay Range*

$48.14 - $69.80 /hour

Seniority level

• Seniority level

  Not Applicable

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Wellness and Fitness Services, Hospitals and Health Care, and Medical Practices

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