Utilization Manager, RN New

JOB SUMMARY: Responsible for providing operational leadership to the day-to-day function of the UM Prior Authorization, Inpatient Teams and Case Management Teams. The UM Manager will ensure that the team complies with Federal, State, Health Plan and NCQA requirements.

ESSENTIAL JOB FUNCTIONS:

1. Collaborating with clinical and non-clinical personnel providing timely care which complies with generally accepted standards of clinical practice.
2. Assigns work schedules, delegates reviews, provides direction on review priorities, meets the demands of internal and external partners, and ensures staff achieve performance goals and adherence to company policies.
3. Ensures that the UM team is properly trained to conduct medical necessity reviews on incoming pre-service/prior authorization, on routine and expedited referrals requests in compliance with Federal, State, Health Plan and NCQA standards.
4. Ensures UM team documents on the medical management system timely, all supporting clinical information, outreach attempts and criteria used to make a determination.
5. Monitors, tracks, and reports any inappropriate referral patterns to the UM Medical Director and Director of Clinical Services
6. Serves as a subject matter expert on appropriate use, interpretation and documentation of clinical criteria in the review process using NCD, LCD, Health Plan Medical Guidelines, MCG, NCCN, etc.
7. Conduct inpatient huddles to review inpatient census including Inpatient CMs and CMO to discuss cases and discuss barriers of discharge plannings.
8. Conduct Annual IRR Reviews for clinical staff by using case studies via MCG Learning Module.
9. Conduct Annual IRR Reviews for non-clinical staff by administering quiz.
10. Prepare and participate in internal and external audits. Health plan, CMS, NCQA, DHCS, state or federal exchange.
11. Develop and revising UM program, workplans and policies and procedures.
12. Prepare and update quarterly, semi-annually and annual um workplans.
13. Participate in committee and sub committee meetings and other meetings as needed.

Prepare and submit compliance reports related to UM activities