- Direct Placement
- Utilization Management
- Alhambra, CA
Our client is a Managed Services Organization serving the rapid growth of its IPAs and Medical Groups, dedicated to delivering administrative support enabling the delivery of quality patient care and services to over 650,000 members here in California.
UM Supervisor – (LVN)
To implement the effectiveness and best practices of Utilization Review, provide direction and supervision to Clinical Staff on overall UR functions and department effectiveness in compliance with NCQA and Health Plan standards.
DUTIES & RESPONSIBILITIES
- Annual review of the P&Ps of the company and ensure staff reviews.
- Comply with all UM policy and procedures.
- Supervisor assigns nurses/clinical staff daily assignments to ensure TAT.
- Utilize available reports to ensure we are meeting established TATs.
- Responsible for assigning coverage to the UR Inquiry emails for multiple IPAs as needed.
- Process routine, emergency and urgent treatment authorization requests according to the Policy & Procedure manual.
- Responsible for ensuring that the clinical staff submits authorization reviews to the appropriate Medical Director.
- Responsible for ensuring that all reviews are processed within established TAT
- Assist in obtaining correct verbiage from physician reviewers as necessary for denial letters to assure compliance with Health Plan requirements.
- Work with Member services and UM coordinators to ensure issues are resolved timely and with quality.
- Contact person for the Manager of UR to help resolve issues between IPA & Health Plans.
- Works closely with the denial department to ensure correct criteria utilized in the decision making.
- Training of all clinical staff for the department to ensure consistency.
- Keep staff aware of any new updates and or changes. Coordinator and clinical level staff.
- Assists with Reporting and/or audits as needed
- Report daily to Manager of UR of any activities occurring throughout the day that may require follow-up or intervention.
- Occasional auditing of daily functions of the staff to ensure consistency and quality in their process.
- Provide feedback and work with the Manager for the direct report's annual evaluation.
- Performs related work as required.
- Occasional weekend and or holiday coverage.
- Work with staff to ensure weekends are covered to maintain our TAT.
- Acts as resource and liaison to staff, departments, and health plans.
- Attend IPA and health plan meetings as required.
- Respond to IPA and health plan complaints in a timely manner.
- Attend in-services in regard to new UM responsibilities (CCS, COC and Audit requirements)
- Interacts with the providers or members as appropriate to communicate determination outcomes in compliance with state, federal and accreditation requirements.
- Attend to provider and interdepartmental calls in accordance with exceptional customer service.
- Maintain good relationships with health plans and medical directors.
- Resolve problems that arise with any IPA medical directors.
- Responsible for annual performance reviews and employee disciplinary action as required for the direct reports.
- Performs other duties, projects and actions as assigned
Active California Registered Nurse or Licensed Vocational Nurse license.
- A minimum of five year's health plan, IPA or MSO experience in management.
- Experience with clinical issues, clinical guidelines, case management, & managed care.
- Working knowledge of ICE, Client, DMHC, NCQA, and CMS standards.
- Excellent analytical critical reasoning and interpersonal communication skill.
- Excellent presentation, verbal and written communication skills and ability to collaborate with co-workers, senior leadership and other management.
- Proven ability to prioritized and organize multi-faceted/multiple responsibilities simultaneously in a fast paced, changing environment while meeting deadlines and turnaround time requirements.
- Must be able to work independently utilizing all resources available while staying within the boundaries of duties.
- Must possess the ability to educate and train staff members and other departments as needed
- Ability to keep a high level of confidence and discretion when dealing with sensitive matters relating to providers, members, business plans, strategies and other sensitive information is required.
- Must be ethical and possess the ability to remain impartial and objective.
- Must be able to travel at least 15% of work time.
- Proficient with Microsoft applications', EZCAP, and crystal reports.
- Personal & Professional Qualities
- Punctuality, Creativity, Self-motivation
- Professional appearance and conduct.
- Conceptual and "big picture” understanding
- Able to function independently under time constraints
- Willing to learn and develop new responsibilities and skills.
- Good organization, critical thinking and problem-solving skills.
- Must be detail-oriented and able to work autonomously but also as a team member
- Should have strong communication and customer service skills and respect for confidentiality.
HOURS & COMPENSATION
Monday – Friday; Days
LVN: $28/hr – $35/hr
Full Time, Benefited / Direct Placement