MGR - MEDICAL MGMT
Apply NowCompany: UHS
Location: Riverside, CA 92503
Description:
Responsibilities
SUMMARY: The Manager of Medical Management provides oversight and leadership of all aspects of the Utilization Management (UM) operations and staff to ensure service levels, business functions and goals are met. Develop and foster a professional working relationship with contracted payers to ensure open communication. Development of policies, procedures, and front-line staff practices to ensure contract compliance. Responsible for day-to-day operations of the departmental functions including prior authorization (PA), concurrent review, and direct supervision of the clinical and non-clinical PA and concurrent review teams. Ensure the department meets turnaround times and all other quality measures. The Manager sets and achieves clinical, financial, and utilization goals through effective management, communication, and role modeling. The Manager functions as the internal resource on issues related to the appropriate utilization of resources, coordination of care across the continuum, and utilization review and management. The Manager is responsible for carrying out assignments in a manner that assures success in financial management, human resources management, leadership, quality, and operational management objectives. Participate in as well as lead discussions with Riverside Medical Clinic providers to refine procedures for PA submissions, concurrent review of inpatients, assisting in the development and maintenance of review criteria, developing and coordinating relevant UM activities with the State and CMS, ensuring high meeting activity attendance and submitting reports on time. Will serve as service recovery to PA/Concurrent Review staff as needed
QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential function satisfactorily. 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 essential functions.
Qualifications
EDUCATION and/or EXPERIENCE: Associate degree from an accredited college or a two-year college; a bachelor of nursing or business administration preferred. Four years of related experience are required. Three to five years of program development and Compliance experience are required. Must possess knowledge of delegation oversight, referrals/denials functions, and knowledge of regulatory standards issued by CMS, DMHC, DHCS, and other governing bodies required.
CERTIFICATES, LICENSES, AND REGISTRATIONS: Current, unrestricted California Registered Nurse (RN) license. National certification of any of the following: CPHM (Certified Professional in Healthcare Management), CCM (Certified Case Manager), ACM (Accredited Case Manager) desired.
ESSENTIAL FUNCTIONS:
Essential functions are those tasks, duties, and responsibilities that comprise the means of accomplishing the job's purpose and objectives. Essential functions are critical or fundamental to the performance of the job. They are the major functions for which the person in the job is held accountable. Note: (other duties may be assigned, deleted, or changed at any time, at the discretion of management, formally, or informally, either verbally or in writing).
1. Establish work procedures, development of departmental policies, development of desktop procedures, and establish work processes for direct reports. Ongoing monitoring for compliance.
2. Serves as an internal resource and consultant to management, and medical staff about case management, reimbursement, clinical resource utilization, and care coordination issues
3. Acts as a liaison between the patient/family, physician, and patient care team as necessary to problem solve.
4. Participates in the development and management of department budgets and productivity targets.
5. Prepare work schedules, maintain employee attendance records, and submit time sheets to payroll. Interviewing, hiring, and coordination of onboarding for new staff.
6. Responsible for staff coaching, 90-day assessments, annual performance evaluations, and ongoing training/evaluation of staff performance.
7. Manages human resources utilization, promotes employee satisfaction, supports staff development, and utilizes the progressive discipline process when appropriate, ensuring all documentation about employee issues, training records, and any related company policies and procedures are in compliance with governmental and company protocols.
8. Assists the Regional Director of Quality Risk & Utilization Management with policy development in all areas to ensure adherence to protocols and administrative requirements.
9. Ensure staff compliance with all regulatory standards issued by CMS, DMHC, and HMO Health Plans. Ensure that RMC is in compliance with current legislative requirements. Coordinate with the Regional Director of Quality Risk & Utilization Management for strategic planning, preparation, and participation for audits by Health Plans.
10. Establish caseload assignments and measurable productivity metrics. Monitor staff productivity.
11. Receives all denials for care involving patient stays, discusses with UR Physician Advisor, feasibility to appeal. Manages all appeals related to denials of patient stays for all payors/insurance companies.
12. Oversight of direct reports to ensure compliance with industry standards, turnaround times, report validation and submission, appropriateness with approval/denials process and documentation, oversight with utilization management, and medical necessity.
13. Participate in all delegation oversight team-related audits, and present findings to the management team. Review deficiencies/OFIs and strategize on process improvement and implementation of improvements. Report out relevant practice trends and data to appropriate departments and/or committees. Participate in meetings and trainings with Health Plans as requested.
14. Participates in quality improvement processes and assures implementation of regulatory standards. Prepare for, participate in, and report out on all Quality/UM-related Committees and collaborate with responsible administrators for the different committees. Ensure any reports are completed and submitted before the meeting.
15. Collaborate with the UM Medical Director on goal-setting for improving/sustaining high-quality measures for the department.
16. Assume any other responsibilities as directed by the Regional Director of Quality Risk & Utilization Management related to CM/UM, Inpatient, Ambulatory, and Outpatient services.
THIS OPPORTUNITY OFFERS THE FOLLOWING:
Challenging and rewarding work environment
Growth and Development Opportunities within UHS and its Subsidiaries
Competitive Compensation
ABOUT UNIVERSAL HEALTH SERVICES:
One of the nation's largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World's Most Admired Companies by Fortune; and listed in Forbes ranking of America's Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com
EEO STATEMENT:
All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.
We believe that diversity and inclusion among our teammates is critical to our success.
AVOID AND REPORT RECRUITMENT SCAMS:
At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc.
If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.
SUMMARY: The Manager of Medical Management provides oversight and leadership of all aspects of the Utilization Management (UM) operations and staff to ensure service levels, business functions and goals are met. Develop and foster a professional working relationship with contracted payers to ensure open communication. Development of policies, procedures, and front-line staff practices to ensure contract compliance. Responsible for day-to-day operations of the departmental functions including prior authorization (PA), concurrent review, and direct supervision of the clinical and non-clinical PA and concurrent review teams. Ensure the department meets turnaround times and all other quality measures. The Manager sets and achieves clinical, financial, and utilization goals through effective management, communication, and role modeling. The Manager functions as the internal resource on issues related to the appropriate utilization of resources, coordination of care across the continuum, and utilization review and management. The Manager is responsible for carrying out assignments in a manner that assures success in financial management, human resources management, leadership, quality, and operational management objectives. Participate in as well as lead discussions with Riverside Medical Clinic providers to refine procedures for PA submissions, concurrent review of inpatients, assisting in the development and maintenance of review criteria, developing and coordinating relevant UM activities with the State and CMS, ensuring high meeting activity attendance and submitting reports on time. Will serve as service recovery to PA/Concurrent Review staff as needed
QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential function satisfactorily. 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 essential functions.
Qualifications
EDUCATION and/or EXPERIENCE: Associate degree from an accredited college or a two-year college; a bachelor of nursing or business administration preferred. Four years of related experience are required. Three to five years of program development and Compliance experience are required. Must possess knowledge of delegation oversight, referrals/denials functions, and knowledge of regulatory standards issued by CMS, DMHC, DHCS, and other governing bodies required.
CERTIFICATES, LICENSES, AND REGISTRATIONS: Current, unrestricted California Registered Nurse (RN) license. National certification of any of the following: CPHM (Certified Professional in Healthcare Management), CCM (Certified Case Manager), ACM (Accredited Case Manager) desired.
ESSENTIAL FUNCTIONS:
Essential functions are those tasks, duties, and responsibilities that comprise the means of accomplishing the job's purpose and objectives. Essential functions are critical or fundamental to the performance of the job. They are the major functions for which the person in the job is held accountable. Note: (other duties may be assigned, deleted, or changed at any time, at the discretion of management, formally, or informally, either verbally or in writing).
1. Establish work procedures, development of departmental policies, development of desktop procedures, and establish work processes for direct reports. Ongoing monitoring for compliance.
2. Serves as an internal resource and consultant to management, and medical staff about case management, reimbursement, clinical resource utilization, and care coordination issues
3. Acts as a liaison between the patient/family, physician, and patient care team as necessary to problem solve.
4. Participates in the development and management of department budgets and productivity targets.
5. Prepare work schedules, maintain employee attendance records, and submit time sheets to payroll. Interviewing, hiring, and coordination of onboarding for new staff.
6. Responsible for staff coaching, 90-day assessments, annual performance evaluations, and ongoing training/evaluation of staff performance.
7. Manages human resources utilization, promotes employee satisfaction, supports staff development, and utilizes the progressive discipline process when appropriate, ensuring all documentation about employee issues, training records, and any related company policies and procedures are in compliance with governmental and company protocols.
8. Assists the Regional Director of Quality Risk & Utilization Management with policy development in all areas to ensure adherence to protocols and administrative requirements.
9. Ensure staff compliance with all regulatory standards issued by CMS, DMHC, and HMO Health Plans. Ensure that RMC is in compliance with current legislative requirements. Coordinate with the Regional Director of Quality Risk & Utilization Management for strategic planning, preparation, and participation for audits by Health Plans.
10. Establish caseload assignments and measurable productivity metrics. Monitor staff productivity.
11. Receives all denials for care involving patient stays, discusses with UR Physician Advisor, feasibility to appeal. Manages all appeals related to denials of patient stays for all payors/insurance companies.
12. Oversight of direct reports to ensure compliance with industry standards, turnaround times, report validation and submission, appropriateness with approval/denials process and documentation, oversight with utilization management, and medical necessity.
13. Participate in all delegation oversight team-related audits, and present findings to the management team. Review deficiencies/OFIs and strategize on process improvement and implementation of improvements. Report out relevant practice trends and data to appropriate departments and/or committees. Participate in meetings and trainings with Health Plans as requested.
14. Participates in quality improvement processes and assures implementation of regulatory standards. Prepare for, participate in, and report out on all Quality/UM-related Committees and collaborate with responsible administrators for the different committees. Ensure any reports are completed and submitted before the meeting.
15. Collaborate with the UM Medical Director on goal-setting for improving/sustaining high-quality measures for the department.
16. Assume any other responsibilities as directed by the Regional Director of Quality Risk & Utilization Management related to CM/UM, Inpatient, Ambulatory, and Outpatient services.
THIS OPPORTUNITY OFFERS THE FOLLOWING:
Challenging and rewarding work environment
Growth and Development Opportunities within UHS and its Subsidiaries
Competitive Compensation
ABOUT UNIVERSAL HEALTH SERVICES:
One of the nation's largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World's Most Admired Companies by Fortune; and listed in Forbes ranking of America's Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com
EEO STATEMENT:
All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.
We believe that diversity and inclusion among our teammates is critical to our success.
AVOID AND REPORT RECRUITMENT SCAMS:
At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc.
If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.