Description
SHIFT: No Weekends
SCHEDULE: Full-time
Do you have the career opportunities you want in your current role? We have an exciting opportunity for you to join the nation's largest provider of healthcare services as a Nurse Utilization Management Manager.
HCA Healthcare is a national leader in providing modern, culturally competent, patient-centered care and we are driven by a single goal: the care and improvement of human life.
We offer you an excellent total compensation package, including competitive salary, excellent benefit package and growth opportunities. We believe in our team and your ability to do excellent work with us. Your benefits include 401k, PTO medical, dental, flex spending, life, disability, tuition reimbursement, employee discount program, employee stock purchase program. We would love to talk to you about this fantastic opportunity.
The HCA Physician Services Group (PSG) is the physician and practice management solution for the Hospital Corporation of America (HCA). We lead a collection of highly motivated healthcare professionals just like you and creative leaders who are committed to excellence in every patient interaction. Are you excited yet?
Pacific Partners Management Services (PPMSI) is a managed services organization formed in 1997 with administrative offices located in Foster City, CA. We provide services to IPAs in the Santa Clara and Monterey Bay areas. Our managed care and ACO services support approximately 1,000 independent physicians and include executive management, full financial services, utilization management, quality improvement, credentialing, contracting, claims processing and provider and member network services.
PPMSI is part of HCA Physician Services Group (PSG), the physician and practice management solution for the Hospital Corporation of America (HCA). PSG operates more than 750 practices, Urgent Care Facilities, and partners with HCAs 165 hospitals to structure employed provider programs, professional service agreements, and joint ventures that offer the communities we serve high quality, cost effective care. We manage a collection of highly motivated and innovative leaders who are committed to excellence in every aspect of their career.
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What you will do in this role:
The Utilization Management (UM) Managers primary function is to ensure timely review of referral requests, procedure, and pre-certification requests in accordance with established policy.
DUTIES AND ESSENTIAL JOB FUNCTIONS
- Document department policies and procedures in coordination with the Medical Director and CMO revising procedures as necessary.
- Assist with compiling training manuals, training staff and revise training manuals as necessary.
- Oversee preauthorization of managed care services. Ensure that notification of approvals/denials for services meet HMO and regulatory contractual guidelines.
- Interview, hire, train, and discipline direct reports and supervise department staff.
- Document, conduct, and/or review employee performance appraisals.
- Maintain accurate individual performance records and manage actual performance to meet expected performance levels
- Perform quality audits on responses to authorizations received telephonically and electronically.
- Contact providers and/or provider office staff to request additional medical information, as required evaluating complex authorization requests.
- Coordinate patient care information with utilization management, concurrent review nurses and case managers.
- Collect and report risk management and potential quality of care events to Medical Director and QI.
- Serve as liaison with health plans and providers for complex or sensitive member issues.
- Working knowledge of all regulatory requirements, i.e. NCQA, HEDIS, CMS and required reporting.
- Responsible to manage health plan audits and reporting for UM and Medical Management related requirements.
- Inform Medical Director of system and operational issues and serve as a member of the Management Team.
- Maintain departmental performance standards.
- Understand and effectively manage electronic and non-electronic referral systems.
- Implement UM manual policies and procedures.
- Promotes a cooperative relationship between the HMOs, Providers, Employer Groups and other departments of PPMSI.
- Work with Utilization Management and Quality Improvement, Utilization Review, and Health Plan Compliance to ensure that information concerning managed care is disseminated to appropriate internal and external entities.
- Balance numerous priorities while being creative and results oriented
- Assign staff and supervise work to ensure efficient operation and compliance with standard processes and special projects.
- Monitor and Coordinate Health Plan Compliance.
- Lead, coordinate, and prepare meeting documentation and reports for UM/QI committee meetings.
- Perform any additional tasks as assigned by the Medical Director/CMO.
Qualifications
What Qualifications you will need:
REQUIRED
- Must have a nursing degree from an accredited college or university.
- At least 5 years experience in utilization review or case management within managed care or equivalent experience.
- Ideally supervisory experience in a clinical or administrative setting.
- Proficiency with computers, Outlook, Word, Excel and the Internet.
- Excellent written and verbal communication and presentation skills.
- Ability to maintain confidentiality.
- Ability to travel to medical offices as needed.
REQUIRED LICENSES/CERTIFICATIONS
Current unrestricted R.N or L.V.N. license.
Current and valid California drivers license.
