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Manager, PACE Utilization Management (RN)
- Job ID
Under the direction of the PACE Medical Director, this position is responsible for overseeing and managing the day-to-day operations of the PACE Inpatient Case Management team and PACE Utilization Management team. This position works closely with the PACE Medical Director/s to evaluate and monitor inpatient and UM medical appropriateness determinations and care coordination activities. This position is responsible for developing and implementing strategic plans which will have a direct impact on appropriate resources utilization and improved patient outcomes. The position may be involved in ad hoc projects and analysis of high cost utilization areas, unmanaged care, inappropriate utilization, inappropriate billing practices, and budgeting/finances reporting. May be responsible for identifying high risk patients via inpatient rounds, provider referral patterns, utilization management referrals, and disease registry reporting mechanisms and will refer high risk patients to appropriate PACE site medical leadership for discussion with site team. Effectively collaborates with the partner Hospitalists/SNFists, the hospital nursing/SNF personnel, with members of the PACE interdisciplinary care team and with the community physicians/specialists
- Assesses the non-clinical and clinical staff training needs and completes necessary desktop procedures, workflows, and/or resource guides to assist staff core job functions.
- Responsible for monitoring inpatient rounds and outpatient care team meetings to ensure quality of the exchange of patient information
- Responsible for ensuring staff receive performance data and assist staff with developing plans to meet daily goals.
- Conducts meetings with staff to implement approved Policies and Procedures or workflows as needed.
- Works collaboratively with Hospitalists/SNFists, hospital/snf partners, and PACE IDT care teams to provide holistic, high quality patient care that is focused on high quality in a cost effective
- Assists with composing medical director denials to meet language requirements set by PACE requirements
- Utilizes authorization matrix, ancillary rosters, and/or hospital/vendor agreements to drive decision-making
- Maintains up to date knowledge of PACE rules and regulations governing utilization management processes;
- Input data into the Authorization system to ensure timeliness of referral processing.
- Ensure timely provider and member oral and written notification of referral decisions.
- Coordinates with Medical Director, UM nurses and referral specialists for timely referral processing
- Performs trouble-shooting when problems situations arise; taking independent action to resolve the less complex issues.
- Participate in ad hoc projects and analysis of high cost utilization areas, unmanaged care, inappropriate utilization, inappropriate billing practices, and budgeting/finances reporting
- Will participate in the developing of all program material, Policies and Procedures related to the PACE Utilization Management; to include, the development of informational, training and educational materials
- Develops a positive working relationship with internal and external customers
- Responsible for daily coverage needs for inpatient concurrent reviews, discharge planning, Utilization Management authorization request review, and ensures patients meet appropriate level of care based on acceptable evidence-based Clinical Criteria(s)
- Follows established policies, procedures, workflows, and desktop procedures of the department.
- Attends hospital rounds routinely with PACE Medical Directors and hospitalists to oversee inpatient delivery of care and discharge planning.
- Attends PAE Utilization Management Meetings and various community meetings as needed.
- Responsible for the oversight and coverage needs for daily review and processing of referral authorizations in accordance to turnaround time (TAT) standards set by PACE regulations requirements.
- Performs other related duties as assigned.
Measurements of Success:
I. MEETS PERFORMANCE REQUIREMENTS
- Meet the established Performance & Productivity Targets. Measurement: Department’s Performance Metrics.
- Effective time management demonstrated by meeting all regulatory and health plan requirements. Measurements, 100% of audits completed and documents submitted within the required time line.
- Managing multiple priorities, demonstrated by ease and productivity to transition between multiple tasks. Measurement, Department Performance Measure.
- Team player, measured through assisting co-workers with their workload as asked by the Manager/Supervisor/Lead or others and completed cross-training, and serve in roles not their own during the year.
- Meet Productivity Targets, as managed and communicated through the Productivity Report.
- Highly effective communication with members, external constituents, and internal stakeholders. Measurement, employee engagement.
- Leading by example. Be the role model in offering supportive care to patients, and consistently meet needs of the external and internal customers. This is measured by AIDET Validation and input from the clinics and other customers obtained as a part of the annual Performance Review
II. EXCEEDS PERFORMANCE REQUIREMENTS
- All items listed under "Meets Expectations", and;
- Problem solving skills demonstrated by identification, recommendation, and implementation of tactics and approaches to improve productivity and team work.
- Taking initiations demonstrated by consistent and active offer participation to be a positive change agent, to problem solve, identify and offer. suggestions to improve outcomes in the PACE UM department and to assist others as needed.
- Currently licensed as an RN and registered to practice in the State of California with the State Board of Nursing (RN) coupled with a minimum of five Years of experience in managed care at the hospital, IPA/MSO or insurance industry level, with at least 1+ year in a supervisory capacity or its equivalent preferred.
- BSN highly preferred
- Knowledge of State and Federal regulations also required.
- Experience with Interqual and/or Milliman preferred.