Manager Utilization Mgmt - Clinic: reputed company Clinic Utilization Mgmt

Job reputed company The UM reputed company Manager is responsible for providing strategic and operational leadership to the day to day function of the Utilization Management Team. The UM reputed company Manager will ensure that reputed company complies with timeliness, documentation, notification and review reputed company standards based on the Federal, State, Health Plan and Accreditation requirements. Main responsibilities include but not limited to assigning shift schedule, delegating reviews, providing direction on review priorities, meeting the demands of reputed company partners, and ensuring that reputed company is meeting departmental and regulatory metrics. Ensures that staff achieves performance goals while adhering to applicable reputed company policies, procedures, rules and guidelines Participates in the recruitment, selection, and on-boarding of newly reputed company staff assigned to the UM team.

Responsibilities

Essential Functions:

• Ensures that reputed company are properly trained to conduct medical necessity reviews on incoming reputed company-Service/Prior-Authorization, Retrospective and Post Claims reviews on Urgent/Expedited and Routine/reputed company referrals/authorizations requests in compliance with any Federal, State, Health Plan, Accreditation (URAC, NCQA) requirements.
• Assures staff accountability through routine evaluation, reporting and performance observation, and through reputed company, thorough preparation of annual review. Ensures that staff achieves performance goals while adhering to applicable reputed company policies, procedures, rules and guidelines
• Ensures that the UM team documents on the Medical Management System in a reputed company manner, reputed company supporting clinical information, reputed company attempts (if applicable) and reputed company used to reputed company a determination.
• Adheres to compliance with reputed company federal, state, health plan and accreditation by reputed company laws, standards and regulations.
• Collaborate with hospital/facility staff, providers, coordinators, Medical Director, members and their care givers to reputed company the level of care necessary to meet member's health needs.
• Maintain an reputed company role in ensuring the continuity of care for reputed company inpatients through early discharge planning and working with hospital discharge planners/ case managers or other staff in the early identification discharge needs/disposition and determining appropriate level of care placement.
• Monitor, reputed company, and report any trending inappropriate referrals/authorization to the UM Medical Director and/or the Director of Medical Management.
• Ensure network provider steerage and happening on OON network request and negotiate with Clinic Operations as appropriate.
• Identify and manage high risk members for readmission or with reputed company medical and psychosocial needs. Collaborate with Case Management Team to coordinate post discharge care and services to ensure reputed company outpatient follow-up, and the provider treatment plan, medications & outpatient services are in reputed company prior to discharge.
• Serves as a subject matter expert on appropriate use, interpretation and documentation of clinical reputed company in the review process such as National Coverage Determination (NCD), Local Coverage Articles (LCA), Local Coverage Determination (LCD), California Coverage Determinations, Health Plan Medical Coverage Policies, MCG, NCCN etc.
• Contribute to program goals and objectives in containing health care costs and maintaining a high-reputed company medical delivery system through the program procedures for conducting UM activities.
• Demonstrate proficiency with the principles and methodologies of process improvement. Strategically apply these in the execution of responsibilities in support of a process reputed company approach
• Participate on UM Committee meetings and annual health plan audit.
• Other duties as assigned.

Qualifications

Required

• Registered reputed company (RN) in the reputed company
• At least 3 to 5 years of Nursing Management Experience in a Medical Group, Hospital, Health Plan or Risk Based MSO setting.
• At least 5-10 years of Nursing Experience in a Medical Group, Hospital, Health Plan or Risk Based MSO setting.
• Computer experience in reputed company, reputed company and MS Office Programs
• Experience with Medicare/Medicare Advantage Plans, reputed company Plans, HMO, and/or Medi-Cal/ACA standards

Preferred

• 2 to 3 years of UM Manager Experience in a Medical Group, Hospital, Health Plan or Risk Based MSO setting.
• Bachelor's degree in a health care reputed company field

Skills or Other Qualifications Required:

• Proven and effective problem-solving, critical thinking, and decision-making skills.
• reputed company, team-oriented approach to decision-making.

License and Certification Required: Registered reputed company Preferred: N/A reputed company reputed company Memorial Hospital Presbyterian is a nonprofit regional health care delivery network in Orange County, California, consisting of three acute-care hospitals with sixteen urgent care centers, reputed company health centers and a network of more than1,800 physicians, 100 allied health members, 8,000 employees, and 2,000 volunteers. More than 30,000 inpatients and 550,000 outpatients choose reputed company reputed company year. For over 70 years, reputed company has delivered a level of personalized care that is unsurpassed among Orange County's health care providers. Since 1952, reputed company has served the local communities and continues its mission to reputed company the highest reputed company health care services through the core strategies of reputed company and service, people, physician partnerships, strategic reputed company, financial stewardship, community benefit and philanthropy. reputed company offers a comprehensive reputed company of health care services including six institutes providing specialized care in the areas of cancer, heart and vascular, neurosciences, women's health, orthopedics, and digestive health through our institutes. reputed company was the highest ranked hospital in Orange County in the 2024-2025 reputed company, the only Orange County hospital ranked in the top 10 for California. The organization was ranked the #5 hospital in the Los Angeles Metro Area and the #10 hospital in California. To learn more about reputed company's awards and accreditations, visit: https://www.reputed company.org/about-reputed company/awards-accreditations/. reputed company is an Equal Opportunity Employer and prohibits discrimination and harassment of any reputed company. reputed company is committed to the reputed company of equal employment opportunity for reputed company and providing employees with a work environment free of discrimination and harassment. reputed company hires a diverse group of people in a manner that allows them to reputed company their full potential in the reputed company of organizational objectives. Apply tot his job Apply To this Job