Under the supervision of the CBDO, responsible for assuring the receipt of high quality, cost efficient medical outcomes for patients.
ESSENTIAL FUNCTIONS AND RESPONSIBLITIES
1. Develops and administers policies and procedures for utilization control of outpatient and outside referral services. Assists in the development and implementation of procedures to track and trend specialty and ancillary service utilization within the health centers.
2. Responsible for monitoring referral patterns and making recommendations to the Chief Medical Officer on strategies to contain costs, improve access and ensure quality care; and ensures implementation of practice guidelines and referral criteria established by the Chief Medical Officer.
3. Responsible for the maintenance of good community relationships with providers who provide services to MedPartners patients and ensures a responsive system for authorization of services and payment of claims; and assisting in negotiating access to care in targeted areas, as requested.
4. Prepares statistical and narrative reports as requested by management on utilization patterns, expenditures by area and revenue stream, demographics of service delivery and trending of expenditures by program.
5. Establishes and amends, as necessary, a reporting system for contract providers; monitors and analyzes the use of services from outside providers.
6. Trains professional clinic staff on current standards of Utilization Management, medical/surgical diagnosis and treatment coding and reimbursement methodologies.
7. Reviews incident reports and responds to grievances filed on behalf of members related to quality concerns.
8. Serves on Safety, Performance and Quality Improvement (P/QI), and Compliance Committees. Presents data, trends, and grievances as applicable to identify how to measures to improve processes and mitigate risk moving forward.
9. Conducts or oversees Facility Site Reviews of contracted providers per regulatory requirements to ensure compliance with quality, safety, and accessibility standards.
10. Responsible for day to day supervision, staff training, monitoring documentation and available resources.
11. Performs other duties as assigned including participation in all safety programs which may include assignment to an emergency response team.
This is an excellent opportunity to work for an organization that truly makes a difference in the community. Clinicas Del Camino Real, Inc. offers a highly competitive salary; excellent benefit package including full medical, dental, vision, life and disability insurance; generous holiday, vacation and sick leave.
EDUCATION, EXPERIENCE AND QUALIFICATIONS
Registered Nurse. Two years of experience in utilization review in a hospital or health care setting, including one year of supervisory experience; or, equivalent combination of training, education, and experience that would provide the required knowledge, abilities and license.
Must have working knowledge of state regulations applicable to treatment and reimbursement under Managed Care programs such as Medi-Cal, Medicare, Medicaid; utilization review procedures and techniques; medical and surgical diagnoses, procedures and types of treatment; Medi-Cal Social Services in ambulatory care; applicable State of California and local health and managed care regulations; statistical and fiscal data collection and interpretation.
Must have ability to plan, organize and administer Utilization Management and Quality Assurance programs effectively; communicate with others effectively; write clear and concise correspondence using correct grammar, punctuation, and spelling; identify medical utilization needs; establish priorities, gather analyze and report data; familiar with development of quality assurance program under managed care; analyze program regulations and laws governing health care to insure legally compliant program design and mitigate risk; ability to communicate effectively orally and in writing; ability to lead change; ability to work effectively with clinics, providers and the community.