Manager of Specialty Care Services & Utilizat
Apply NowCompany: Los Angeles LGBT Center
Location: Los Angeles, CA 90011
Description:
Position: Manager, Specialty Care Referral Services & Utilization Review
Program: Specialty Care Referral Services & Utilization Review
Department: Health Services
Reports to: Co-Director, Health Services
Compensation: $87,879-$92,761 Annually
Status: 100%, Full-Time, Regular, Exempt
Probation: 180 days
Benefits: Medical, Dental, Vision, Life, and Long-Term Disability Insurance, Employee Assistance Program, and 403(b) Retirement Plan
CENTER'S MISSION: Building a world where LGBT people thrive as healthy, equal, and complete members of society.
DEPARTMENT SUMMARY: As the nation's largest and most experienced provider of LGBT medical and mental health services, we help LGBTQ people lead healthier, happier lives, by keeping their minds and body well. All services are free or low cost. We're also one of the few Federally Qualified Health Centers in the nation with providers who specialize in primary care for LGBTQ people and with a research team working to advance the care and treatment of people in our community.
JOB SUMMARY: The Manager, Specialty Care Referral Services and Utilization Review oversees the coordination and management of referrals from primary care to specialty care providers while ensuring adherence to utilization review (UR) standards. This role combines efficient referral processes with a focus on optimizing resource use, compliance, and patient outcomes.
% of Role ESSENTIAL FUNCTIONS
40% Leadership, Administration, and Compliance
Ensure alignment of specialty care referral activities with departmental goals.
Develop and refine workflows to improve the efficiency, accuracy, and compliance of the referral process.
Implement and manage a Utilization Review program to evaluate medical necessity, optimize service use, and avoid duplication of care.
Act as a point of escalation for complex referral or utilization management issues, collaborating with payers and internal teams to resolve challenges.
Lead initiatives to evaluate and improve departmental performance related to referrals, utilization review, and care coordination.
Support the development and implementation of policies and procedures for specialty care referral services.
20% Program Planning and Quality Management
Track and report key metrics, including referral volume, cycle times, approval rates, denial trends, and patient outcomes.
Lead quality improvement initiatives, including identifying gaps, developing solutions, and implementing process enhancements.
Monitor and address trends in referral patterns, patient needs, and payer requirements to support continuous improvement.
Monitor program performance and identify opportunities for improvement to enhance service delivery and client outcomes.
Provide support on escalated referral and patient issues, acting as a resource for both staff and external partners.
Participate in quality management activities, including data collection, performance reporting, and compliance reviews.
Collaborate on special projects and initiatives to address service gaps and improve client care.
Prepare and present performance and activity reports to senior leadership, highlighting achievements and opportunities for improvement.
20% Interdisciplinary Collaboration
Work closely with case management, primary care providers, specialty providers, and ancillary services to ensure seamless coordination of care.
Serve as a liaison between specialty care referral services and other departments to promote communication, service coordination, and resource allocation.
Collaborate with insurance companies' utilization management (UM) teams to streamline service authorizations.
Address patient barriers to accessing specialty care, such as insurance, transportation, or health literacy challenges, by collaborating with internal and external stakeholders.
Build relationships with community partners to connect clients to additional resources and services.
5% Other Duties
Represent the Center at community events, conferences, and meetings to build partnerships and enhance services, such CCALAC and CPCA roundtables.
Perform additional duties as needed to advance the Center's mission.
15% Management Responsibilities (Budgetary & Direct Supervisory)
Supervise and mentor the Specialty Care Supervisor and THP Specialty Care Administrator to ensure effective referral operations.
Collaborate on workforce planning, including staff recruitment, onboarding, and development.
Develop and implement staff training programs to improve knowledge of referral workflows, compliance standards, and utilization management practices.
Conduct periodic performance evaluations, providing timely feedback and addressing challenges effectively.
Maintain staffing levels to meet program demands while ensuring a positive, collaborative work environment.
REQUIRED QUALIFICATIONS
Knowledge of and experience working with the LGBTQ+ community, including an understanding of issues relevant to LGBTQ+ individuals.
A passion for the Center's mission to improve the lives of LGBTQ+ individuals. Minimum 3 years' experience in direct patient care.
Minimum 3 years' experience in direct patient care.
Minimum of 3 years of experience in Case Management and utilization management.
Minimum of 3 years of management experience
Knowledge of trauma-informed care, conflict resolution, and motivational interviewing.
Knowledge of HIV/AIDS, infectious diseases, and chronic disease management.
Strong understanding of healthcare quality improvement, budgeting, and reporting requirements (e.g., HEALTH PLANS, HRSA, FQHC, PCMH).
Familiarity with value-based care models (e.g., ACOs, bundled payments) and how these impact referrals and utilization.
Demonstrated experience with payer relations, including working with Medicaid, Medicare Advantage, and commercial insurers, to ensure effective utilization review processes and compliance with payer criteria.
Strong communication, organizational, and interpersonal skills with a high level of attention to detail.
Proficiency with Microsoft Office, Electronic Health Records (EHR), and other healthcare software systems.
Proficiency making data-driven decisions using analytics tools, dashboards, and reports, to track referrals and utilization trends.
Demonstrated ability to manage multiple priorities, maintain strict confidentiality, and perform tasks with minimal supervision.
Ability to work independently with minimum supervision.
Demonstrated ability to work effectively in a multicultural environment with diverse populations, including different races, ethnicities, nationalities, sexual orientations, gender identities, gender expressions, socio-economic backgrounds, and physical abilities.
REQUIRED EDUCATION AND LICENSURE
Current California LVN or RN license required.
PREFERRED QUALIFICATIONS
Bachelor of Science in Nursing (BSN).
The Los Angeles LGBT Center is an Equal Opportunity Employer and is committed to fostering diversity within its staff. Applications are encouraged from all persons regardless of their race, color, ancestry, national origin, sexual orientation, gender identity and expression, sex, pregnancy, childbirth and related medical conditions, religion, disability, age, military or veteran status, including status as a victim of domestic violence, assault or stalking, genetic information (including family medical history), political affiliation or activities, medical or health conditions, and marital status.
The Center has implemented a mandatory COVID-19 vaccination policy as a condition of employment for all employees who work on the Center's premises, subject to applicable federal, state, and local laws. For more information, please contact [redacted].
Program: Specialty Care Referral Services & Utilization Review
Department: Health Services
Reports to: Co-Director, Health Services
Compensation: $87,879-$92,761 Annually
Status: 100%, Full-Time, Regular, Exempt
Probation: 180 days
Benefits: Medical, Dental, Vision, Life, and Long-Term Disability Insurance, Employee Assistance Program, and 403(b) Retirement Plan
CENTER'S MISSION: Building a world where LGBT people thrive as healthy, equal, and complete members of society.
DEPARTMENT SUMMARY: As the nation's largest and most experienced provider of LGBT medical and mental health services, we help LGBTQ people lead healthier, happier lives, by keeping their minds and body well. All services are free or low cost. We're also one of the few Federally Qualified Health Centers in the nation with providers who specialize in primary care for LGBTQ people and with a research team working to advance the care and treatment of people in our community.
JOB SUMMARY: The Manager, Specialty Care Referral Services and Utilization Review oversees the coordination and management of referrals from primary care to specialty care providers while ensuring adherence to utilization review (UR) standards. This role combines efficient referral processes with a focus on optimizing resource use, compliance, and patient outcomes.
% of Role ESSENTIAL FUNCTIONS
40% Leadership, Administration, and Compliance
Ensure alignment of specialty care referral activities with departmental goals.
Develop and refine workflows to improve the efficiency, accuracy, and compliance of the referral process.
Implement and manage a Utilization Review program to evaluate medical necessity, optimize service use, and avoid duplication of care.
Act as a point of escalation for complex referral or utilization management issues, collaborating with payers and internal teams to resolve challenges.
Lead initiatives to evaluate and improve departmental performance related to referrals, utilization review, and care coordination.
Support the development and implementation of policies and procedures for specialty care referral services.
20% Program Planning and Quality Management
Track and report key metrics, including referral volume, cycle times, approval rates, denial trends, and patient outcomes.
Lead quality improvement initiatives, including identifying gaps, developing solutions, and implementing process enhancements.
Monitor and address trends in referral patterns, patient needs, and payer requirements to support continuous improvement.
Monitor program performance and identify opportunities for improvement to enhance service delivery and client outcomes.
Provide support on escalated referral and patient issues, acting as a resource for both staff and external partners.
Participate in quality management activities, including data collection, performance reporting, and compliance reviews.
Collaborate on special projects and initiatives to address service gaps and improve client care.
Prepare and present performance and activity reports to senior leadership, highlighting achievements and opportunities for improvement.
20% Interdisciplinary Collaboration
Work closely with case management, primary care providers, specialty providers, and ancillary services to ensure seamless coordination of care.
Serve as a liaison between specialty care referral services and other departments to promote communication, service coordination, and resource allocation.
Collaborate with insurance companies' utilization management (UM) teams to streamline service authorizations.
Address patient barriers to accessing specialty care, such as insurance, transportation, or health literacy challenges, by collaborating with internal and external stakeholders.
Build relationships with community partners to connect clients to additional resources and services.
5% Other Duties
Represent the Center at community events, conferences, and meetings to build partnerships and enhance services, such CCALAC and CPCA roundtables.
Perform additional duties as needed to advance the Center's mission.
15% Management Responsibilities (Budgetary & Direct Supervisory)
Supervise and mentor the Specialty Care Supervisor and THP Specialty Care Administrator to ensure effective referral operations.
Collaborate on workforce planning, including staff recruitment, onboarding, and development.
Develop and implement staff training programs to improve knowledge of referral workflows, compliance standards, and utilization management practices.
Conduct periodic performance evaluations, providing timely feedback and addressing challenges effectively.
Maintain staffing levels to meet program demands while ensuring a positive, collaborative work environment.
REQUIRED QUALIFICATIONS
Knowledge of and experience working with the LGBTQ+ community, including an understanding of issues relevant to LGBTQ+ individuals.
A passion for the Center's mission to improve the lives of LGBTQ+ individuals. Minimum 3 years' experience in direct patient care.
Minimum 3 years' experience in direct patient care.
Minimum of 3 years of experience in Case Management and utilization management.
Minimum of 3 years of management experience
Knowledge of trauma-informed care, conflict resolution, and motivational interviewing.
Knowledge of HIV/AIDS, infectious diseases, and chronic disease management.
Strong understanding of healthcare quality improvement, budgeting, and reporting requirements (e.g., HEALTH PLANS, HRSA, FQHC, PCMH).
Familiarity with value-based care models (e.g., ACOs, bundled payments) and how these impact referrals and utilization.
Demonstrated experience with payer relations, including working with Medicaid, Medicare Advantage, and commercial insurers, to ensure effective utilization review processes and compliance with payer criteria.
Strong communication, organizational, and interpersonal skills with a high level of attention to detail.
Proficiency with Microsoft Office, Electronic Health Records (EHR), and other healthcare software systems.
Proficiency making data-driven decisions using analytics tools, dashboards, and reports, to track referrals and utilization trends.
Demonstrated ability to manage multiple priorities, maintain strict confidentiality, and perform tasks with minimal supervision.
Ability to work independently with minimum supervision.
Demonstrated ability to work effectively in a multicultural environment with diverse populations, including different races, ethnicities, nationalities, sexual orientations, gender identities, gender expressions, socio-economic backgrounds, and physical abilities.
REQUIRED EDUCATION AND LICENSURE
Current California LVN or RN license required.
PREFERRED QUALIFICATIONS
Bachelor of Science in Nursing (BSN).
The Los Angeles LGBT Center is an Equal Opportunity Employer and is committed to fostering diversity within its staff. Applications are encouraged from all persons regardless of their race, color, ancestry, national origin, sexual orientation, gender identity and expression, sex, pregnancy, childbirth and related medical conditions, religion, disability, age, military or veteran status, including status as a victim of domestic violence, assault or stalking, genetic information (including family medical history), political affiliation or activities, medical or health conditions, and marital status.
The Center has implemented a mandatory COVID-19 vaccination policy as a condition of employment for all employees who work on the Center's premises, subject to applicable federal, state, and local laws. For more information, please contact [redacted].