Manager of Utilization and Case Management Job in West Hollywood 90046, California US
AMAZING INDIVIDUALS WORKING FOR POSITIVE PEOPLE at AIDS Healthcare Foundation!
Does the idea of doing something that really makes a difference in people’s lives while being well-compensated intrigue you? Are you looking to work for an organization that encourages growth and success from each and every one of its employees? If so, AIDS Healthcare Foundation is the place for you!
Founded in 1987, AIDS Healthcare Foundation is the largest specialized provider of HIV/AIDS medical care in the nation. Our mission is to provide cutting edge medicine and advocacy, regardless of ability to pay. Through our healthcare centers, pharmacies, health plan, research and other activities, AHF provides access to the latest HIV treatments for all who need them.
AHF’s core values are to be:
• Patient-Centered
• Value Employees
• Respect for Diversity
• Nimble
• Fight for What’s Right
This opportunity is to work on a Fulltime, Regular basis, and it is based out of our Administrative Office, located at 1001 N. Martel Avenue, Los Angeles, CA 90046. The hours are Monday-Friday, From 8:30 a.m. to 5:30 p.m., we offer a competitive compensation, excellent benefits, and a great work environment!
Under the general direction of the Director of Utilization and Case Management, the Utilization Management/Case Management (UM/CM) Manager is responsible for; monitoring the department adherence to contractual and regulatory requirements for Medicare, Medicaid and particular Ryan White care management programs as well as departmental policies and procedures; the integrity of the UM/CM clinical and administrative quality performance measures; the fiscal performance of the UM/CM department as it relates to goals, budget and Medical Loss Ratio (MLR) targets;, and assuring staff performance promotes the principles of assuring that members receive appropriate, indicated, benefit driven high quality cost effective health care in all health care settings.
Will be responsible for the fiscal success of the Inpatient Utilization Management and Prior Authorization departments. In addition this position must successfully execute and supervise key initiatives of the Chronic Care Program, Medical Case Management, the Minority AIDS Initiative Program and the MediCal Waiver Program to ensure compliance with contractual requirements. Evaluate, plan and execute clinical training for new and existing staff as needed. Promote collaboration and teamwork amongst department personnel, other AHF departments and service providers.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Includes the following. Other duties may be assigned.
Duties and Responsibilities include but are not limited to:
• Collaboration with the Department Director and management team in setting goals and the departmental budget.
• In concert with the Director of UM/CM monitors departmental performance against the budget and MLR projections.
• Creates reports involving inpatient utilization, referral patterns, high and low utilizing members and other monitoring activities as they relate to utilization management, fraud/waste/abuse and quality of care and services.
• Coordinates staff schedule to assure effective coverage of UM and CM functions
• Conducts weekly Interdisciplinary Team Rounds, develops agenda, maintains minutes and ensures followed through of action plans
• Promotes alternative care programs and researches available options including costs and appropriateness of patient placement.
• Recommends, coordinates and educates providers regarding alternative care options.
• Develop, update and implement UM/CM policies and procedures, guidelines and action plans as the need necessitates per changes in the department
• Closely monitor inpatient LOS and ensures appropriate and timely discharges
• Maintains an active oversight role in assuring the continuity of care for all inpatients through early discharge/transition of care planning and works with staff, facilities, providers, patients, family/significant others to achieve effective transitions of care.
• Provides orientation and training to all new staff on EZ Cap, PosiTrak, PosiCap and other essential software programs to manage utilization and care coordination.
• Monitor and ensure inpatient cases are entered appropriately into EZCAP and documentation meets department policies and procedures
• Communmicates directly with the Medical director regarding care management issues.
• Provide weekly inpatient utilization report to Director, Medical Director and Chief of Managed Care
• Ensure MediCal TAR’s and retrospective reviews are processed within 3 business days of request
• Review, monitor and execute staff request for Letter of Agreements (LOA), refers all such vendors to Provider Relations and Credentialing for appropriate follow up and credential verification.
• Monitor and evaluate readmissions. Develop action plans with the medical director and the staff responsible for members for all “all-cause” readmissions within 30 days.
• Ensures that approved UM/CM criteria, Plan or contractual benefit parameters and CMS/Medicaid/DHPS rules/regulations/contractual obligations are met for all authorizations, denials, reconsiderations and appeals. Meets all regulatory guidelines and timelines
• Ensures staff orientation and continuing education on InterQual, other clinical criteria, Plan benefit structures and contractual. Develops tools to monitor and evaluate staff compliance to criteria, benefit structure and contractual indicators on a monthly basis.
• Monitor staff documentation and activities against regulatory and program requirements and ensure expectations are met
• Works in collaboration with the Medical Director, UM/CM Director and Quality Management to monitor the execution and effectiveness of the Chronic Care Program.
• Assures interdisciplinary team meetings are scheduled, occur and are documented at each Chronic Care Model Primary Care site and UM/CM weekly meeting.
• Participates with the UM/CM Director, Associate Director of Clinical Education and Quality Management staff in continuing education of PCP sites on the Chronic Care Model. Provide weekly and monthly updates to the Director
• Trains staff in new departmental procedures.
• Collaborates with the Associate Director of Education to ensure ongoing staff education and training for clinical and annual Plan benefit orientation requirements.
• Ensures department programs are compliant to DHCS contractual and regulatory requirements for Medi-Cal, CMS Medicare guidance and regulations, LA County DHSP contractual requirements.
• Ensures staff understands and follows benefits guidelines for all lines of business
• Monitors activities and outcomes against established regulatory and contractual requirements.
• Participates in the development, implementation and monitoring of the annual UM Program Description and UM Work Plan.
• Monitors and evaluates through PosiTrak, PosiCap, and EZCap, the performance of each UM/CM staff member against established productivity, performance and quality measures. Provides timely feedback, individual improvement plans and individual or group training as necessary per department policies, procedures and performance targets.
• Participates in Contracting and Provider Relations activities as necessary to develop and maintain provider networks based on member needs
• Conducts monthly department meetings in the absence of the Director
• Actively participates in the Utilization Management Committee Meetings
• Lead special projects as assigned
Participation in AHF Meetings/Committees
• Attends UM Committee Meeting, assists in the development of the agenda
• Attends AHF and Quality Committee meetings as assigned by the Director of UM/CM.
• Regularly attends the bi-weekly CA Operations meeting
• Leads weekly UM/CM Rounds and Plan/RW IDT
• Develops a calendar and attends each healthcare center IDT at least once per year.
Supervisory Responsibilities
• Maintains, promotes and adheres to AHF Management Principles
• Carries out supervisory responsibilities in accordance with AHF’s policies and applicable laws.
• Interview and hire staff in conjunction with the Director of UM/CM
• Plans orientation and delivers appropriate training for new hires
• Ensures on-going training and development of existing staff
• Assigns and directs work
• Discipline staff in conjunction with Human Resources and AHF guidelines
• In conjunction with the Director of UM/CM, addresses staff concerns and resolves problem
• Prepare and distribute weekly inpatient report. Produce other department reports as directed
Qualifications
To perform this job successfully, an individual must be able to satisfactorily perform the essential duties. 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.
Education and/or Experience
• Graduate from an accredited RN program with three or more years of recent acute hospital or HIV/AIDS nursing experience
• Extensive knowledge Medicare and MediCal regulatory guidelines, benefit management and coverage determination/reconsideration/appeal processes for Medicaid and Medicare
• Three or more years of Inpatient utilization management and denial management required
• Two or more years Case Management experience
• Three or more years of staff supervision/management experience
• Utilization Management certificate upon hire or within one and a half years of employment.
Computer/Software Skills Abilities
To perform this job successfully, an individual must have knowledge of standard business software, including but not limited to: word processing, spreadsheet software, presentation software, experience with relational database principles and functions, and a basic understanding of claims administration principles is required.
Must be able to demonstrate proficiency in the use of Microsoft Word, Excel, Visio, and PowerPoint.
Language Skills
Ability to read, analyze, and interpret the most complex documents. Ability to respond effectively to the most sensitive inquiries or issues.
Mathematical Skills
High mathematical skills required. Ability to apply mathematical principles to practical solutions, using fractions, percentages, ratios, and proportions.
Reasoning Ability
Ability to define problems, collect data, establish facts, and draw valid conclusions.
Travel
Travel required as needed to the Corporate Office, Healthcare Centers, hospitals and members homes.
Other Skills Abilities/Qualifications
Ability to successfully work with various levels of professional and non-professional staff.
Must be able to work independently and as a part of a team.
Knowledge of HIV/AIDS, related medical and patient care issues and concerns in diverse populations.
Ability to analyze data, distil data into information and present reports on utilization trends and findings.
Certificates, Licenses and Registrations
Current California RN License required
BSN or equivalent preferred
CCM or willingness to become CCM certified within 18 months
Current ACRN or certification within 18 months of employment.
ADDITIONAL INFORMATION
Salary: Based on Experience
Location: 1001 N. Martel Avenue, Los Angeles, CA 90046
Position Type: Full Time, Employee
Reference Code: 0708DIRUTCM