Description
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Day - 08 Hour (United States of America)
Why work at Stanford Medicine | Stanford Health Care (SHC)?
Here is your opportunity to mentor and support the UM professionals.
Here is your opportunity to put your UM experience and management skills to drive the continuity of care in this rewarding career.
Benefits begin the first day of the month following employment eligibility.
Our core benefits include medical insurance, dental insurance, vision insurance, an employee assistance program, savings and spending accounts, disability, life and accident insurance, and COBRA. For medical insurance, you have the choice of three generous health plans through Stanford Health Care Alliance, Aetna, or Kaiser Permanente. Each plan includes 100% coverage for preventive care, telemedicine through Teledoc, prescription drug coverage, and behavioral health coverage. Additional incentives exist for healthy choices. And so much more - generous leave & time off, Wellness Program, special programs, educational assistance, and adoption assistance!
**This is an onsite Stanford Health Care job.**
**A Brief Overview**
The Dir-Utilization Management (UM) leads and shapes the UM Strategy, while providing management oversight in implementing, directing, and monitoring the SHC UM Department functions including prior authorizations, utilizing standardized criteria to determine medical necessity, appropriate admission status and continued stay review, retrospective review of care, medical claims review, addressing denials/appeals and grievances effectively and timely, and compliance with payer and regulatory requirements. Directs the UM Department, acts as a subject matter expert, and provides advice and guidance on the Department's functions and overall business operations. Directs, manages, and supervises UM Department staff
**Locations**
Stanford Health Care (Palo Alto, CA; onsite)
**What you will do**
Leads the development of UM strategy by leveraging the use of data/analytics to inform and technology solutions to streamline operational efficiencies while also building a cost-benefit methodology to rationalize decisions on UM reviews to be performed based upon staffing costs, productivity, and projected medical cost savings.
Identifies opportunities to create efficiencies in the UM program and activities, incorporating innovative approaches and solutions, and leading process redesign work necessary to implement improvements.
Directs the utilization management, concurrent review, prior authorizations medical claims review, appeals and grievances functions.
Establishes and measures productivity metrics in order to support workforce planning methodology and rationalization of services to perform UM reviews.
Develops and maintains protocols for Treatment Authorization Request (TAR) authorization criteria.
Ensures contractual turnaround times are met by staff, and performs duties associated with Prior Authorization.
Reviews and reports out on Utilization Review (UR) trending.
Ensures quality of services through UR, review of medical records and provider education, while identifying training opportunities and trends.
Designs, develops, implements, and maintains programs, policies, and procedures in order to meet regulatory, contractual, accreditation, and performance standards.
Evaluates and oversees the implementation recommendations on program changes relative to covered services.
Maintains knowledge of the UM software program functionality and leads the clinical team responsible for advising on replacement, upgrades, and user testing.
Advises and collaborates with the UM/CM Medical Director on strategic issues involving Utilization Management Department programs.
Collaborates with Physician Advisory Services to identify denial root causes and facilitates improvement initiatives and education to address causes.
Develops and maintains collaborative working relationships with payers.
Collaborates with Care Coordination, Clinical Documentation Improvement, Revenue Cycle, providers, and professional services to promote appropriate use of resources.
Maintains knowledge of regulatory and accreditation agencies and related requirements pertinent to utilization management.
Oversees UM Department preparations and responses to regulatory audits and the construction of corrective action plans.
Participates in regulatory audits related to all aspects of utilization management.
Tracks, analyzes, and develops strategies to address outlier performance of utilization metrics and reporting on metrics at a regular cadence.
Conducts UM training for providers and care team members as needed.
Ensures the Utilization Management Department goals and activities are in alignment with the organizations strategic and operational objectives.
Develops performance measures related to strategic goals and new projects and presents to staff and leadership meetings.
Prepares narrative and reports and makes presentations for Utilization Management Committee and other meetings as needed.
Develops and manages the Utilization Management Department operations and budget.
Attends and participates in internal and external meetings.
Collaborates with the UM/CM Medical Director team on complex cases.
Ensures Utilization Management staff maintains up-to-date knowledge, skills, and abilities related to the administration of assigned responsibilities and functions.
Identifies, oversees, and assists with objectives, priorities, assignments, and tasks.
Provides mentoring, coaching, and development and growth opportunities for manager and staff.
Evaluates employee performance, provides feedback to staff, and counsels or disciplines staff when performance issues arise.
Performs other duties as assigned.
**Education Qualifications**
Master's degree in nursing (MSN)
Current unrestricted license as a Registered Nurse issued by the state of California.
National certification of any of the following: CCCM, ACM required within 2 years upon hire.
**Experience Qualifications**
Minimum of five (5) years of utilization management experience
Five (5) years of progressively responsible management experience
**Required Knowledge, Skills and Abilities**
Extensive operational experience in the principles and practices of utilization management, managed care, program planning, implementation, staff development and needs assessment.
Comprehensive kno
Compensation Information:
$0.0 / - $0.0 /
Starting At: 0.0
Up To: 0.0
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