Responsible for developing, integrating, implementing and monitoring compliance with the Utilization Management Plan including policies and procedures across health plans, NCQA and other regulatory agencies. Serves as a liaison between the medical group and the governing agencies in accordance with the Office of the Medical Director/Quality Management Sessions (OMD/QS). Works as a cross-functional team member with Care Management, Quality Improvement, Risk Management, MCA and Contracting.
Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer.
Provides support to the OMD/QS meetings by presenting quarterly on issues/topics related to Utilization Management (UM) including delegation, regulatory requirements, policies, recommendations regarding compliance and utilization/quality issues related to home health and/or durable medical equipment.
Serves as HealthCare Partners (HCP) liaison to the health plans in disseminating information to the Regional Care Management, Quality Improvement and Risk Management departments as appropriate.
Acts as a central resource with regards to regulatory requirements from participating regulatory agencies as well as health plan clinical review criteria and HMO benefits.
Oversees and conducts regional-based training to educate Care Management staff on health plan regulatory procedures and processes.
Responds in writing to all health plan UM requests and determines how best to meet these requests.
Manages, coordinates and facilitates annual health plan audits of components within the HCP corporate and network organizations. Responds in writing to correct any deficiencies.
Assists and facilitates consistency and compliance of Care Management in accordance with health plan, CMS and NCQA requirements. Assists and makes recommendations for any revisions to the UM plan to meet these requirements.
Assists the Regional Care Management departments in the development of the appeals/denials process. Facilitates consistent policies and procedures throughout the organization.
Coordinates the submission of the health plan UM quarterly reports in a timely manner.
Monitors referral turnaround time to meet health plan regulatory compliance.
Oversees the processing and submission of all denial letters company-wide and ensures that denial turnaround times meet health plan regulatory compliance.
Develops UM tools to maintain UM and monitor regulatory compliance.
Participates in the development and implementation of enhancements to the Referral management system.
Maintains the departmental SharePoint site by authorizing, posting and/or updating of documents under the care Management site.
Develops and/or updates the Care Management departmental policies and procedures.
Uses, protects, and discloses HCP patients protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Performs additional duties as assigned.
1 or 2 years of post-high school education or a degree from a two-year college.
Graduate from an accredited school of Nursing.
Current California RN license.
Bachelor s degree preferred.
Over 3 years and up to and including 5 years of experience.
2 to 5 years experience in Quality Management and/or Utilization Management.
5 years management experience, preferably in a medial group / IPA or HMO setting.
KNOWLEDGE, SKILLS, ABILITIES:
Proficient in Microsoft applications (Word, Excel, PowerPoint, Access).
Excellent verbal and written communication skills.
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* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.