Sr. Manager, Utilization Management – Hospital
Sr. Manager, Utilization Management - Hospital - FT
The Manager, Hospital Based Utilization Management directs manages utilization, transitions D/C planning activities programs as organized by the UM department medical center directly associated w/ utilization management of medical services provided to KP members. Essential Functions: - Departmental Operational Oversight - Provides leadership consults w/ other members of the health care team ondifficult discharge cases. - Directs staff review of the UM related aspects of treatment discharge plans to ensure high quality cost-effective discharge planning. - Partners w/ MAPMG in the management of multidisciplinary rounds. - Supports UM staff in negotiating barriers or systems issues to expedite patient services during the hospital stay. - Accountable for oversight of UM activities (e.g., the appropriate use of InterQual, Milliman, or other criteria/guidelines) the denial process. - May be responsible for claims management, repatriation ambulance. - May be responsible for oversight of coordination of care in contracted non-contracted hospitals/providers. - Manages resolves human resource, employee, department safety risk management issues. - Responsible for all aspects of staff management including hiring, development/training, performance reviews terminations integrated into the broader medical center utilization management initiatives. - Shares accountability w/ other medical center regional leadership for the daily monitoring of utilization indicators performance, identification escalation of problems, initiation evaluation of action plans for achieving medical center/hospital targets improving the quality of care services. - Conducts utilization data analysis (avoidable days, readmissions, outlier cases, DRGs, etc.) for trending development of performance improvement initiatives (e.g., LACE readmissions bundle). - Partners w/ the UM APIC, MAPMG health plan local leadership to engage the following areas in the development implementation of a comprehensive utilization management work plan to meet or exceed medical center/hospital targets: physicians, managers across the continuum, MAPMG /health plan leaders managers. Includes oversight of the coordination of KP members care w/ leaders responsible for UM activities across the continuum of care including medical office building clinical decision unit (CDU), core/contracted/non-contracted emergency rooms hospitals. - Identifies incorporates (as appropriate) evidence-based best/successful practices (e.g., care paths, innovative discharge planning/case management models, etc.) in efforts to improve quality of care/service reduce costs. - Administrative Responsibilities - Manages department budget finances. - Develops, implements monitors department policies procedures. - Ensures member benefits are interpreted applied correctly in compliance w/ federal state regulations.This includes oversight of data entry documentation. Qualifications: Basic Qualifications: - 8 years of clinical experience. - 5 years in management/leadership in a hospital or outpatient setting. - 3 years of experience in utilization management activities required. - Current RN licensure in the District of Columbia, Maryland and Virginia required. - BSN or BA in health care related field required or equivalent years of experience. - Graduate of accredited school of nursing. - Knowledge of NCQA standards and other local, state and federal regulations related to UM activities required. - Demonstrated skills in leading and facilitating the efforts of multidisciplinary groups required. - Demonstrated strong communication, problem-solving and analytical skills required. Preferred Qualifications: - Master's degree in health care related field preferred.