Supervisor - Utilization Management Supervisor

POSITION SUMMARY

Promotes timely and appropriate referrals for health care services by assisting clinical staff in the processing of prior authorization requests for ambulatory services and inpatient admissions; appropriate support to the inpatient case management team as they facilitate transitions throughout the continuum to include hospital, skilled nursing facility and custodial stays.

COMPLIANCE WITH REGULATIONS

Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations.

RESPONSIBILITIES

• Supervises staff to ensure all referrals are processed within required timelines.  Activities include but are not limited to:  monitoring daily attendance of all staff to ensure appropriate coverage at all levels of the referrals process; re-prioritizing day to day operations to ensure timely processing of referrals; regularly generating and analyzing data reports to monitor critical performance indicators such as quality of referrals data entry; quality of determination letters andproduction of said letters; assists in the preparation of referrals monthly report.
• Supervises day to day oversight of the Inpatient Support Services activities. This includes but is not limited to the following: monitoring the timeliness, accuracy and dissemination the CHG daily census; facilitation of referrals related to transitions between levels of care (hospital to SNF, SNF to dialysis, etc); issuance of letters of determination (denials, notices of non-coverage, etc); monitoring of ACD line and review of ACD related data; monitors adequacy of intradepartmental staffing. Maintains internal operations and compliance with established standards and timelines by receiving and processing admission notifications and outpatient referral authorization requests via mail, fax, or telephone;
• Provides customer services to external/internal customers by assisting Community Health Group (CHG) contracted facilities, primary care provider sites, specialty and ancillary providers, and members and their families with information regarding access to health care services.
• Assists clinical staff by reporting medical care delivery issues to clinical supervisor; identifying potential over- or under-utilization of services, and gathering data obtained from daily referrals review to assist in reporting primary and specialty care practice patterns; reviewing appropriate coding of services and use of Community contracted providers;.
• Facilitates timely referral turnaround by receiving completed admission or referral requests from facility or clinical staff; entering data and faxing or calling authorization/admission information to appropriate provider.
• Ensures the provision of quality health care by monitoring, in conjunction with clinical staff, member and provider concerns; assisting in resolving problems involving access to appropriate levels of care; completing CQI forms and requesting reports; maintaining confidentiality.

• Contributes to the team effort by co-leading department meetings; giving and receiving feedback; accomplishing related results as needed; assisting clinical staff in identifying areas requiring policies and procedures; working with clinical staff in policy development and periodic policy review.
• Maintains filing system by maintaining accurate files of admissions and authorizations by facility/primary care site; retrieving and/or reproducing files as needed; transferring and archiving documents per department protocols.
• Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.

Qualifications

EDUCATION

• Associates degree or experience in the managed care industry sufficient to demonstrate equivalency knowledge.
• BA degree in medical field preferred.

EXPERIENCE/SKILLS                                                                

• Excellent written and verbal communication skills.

• Must be able to use, apply and teach reference materials, including medical criteria and determination guidelines, appropriately and consistently to non-clinical staff.

• Demonstrated leadership skills.
• Excellent work assessment and analytical skills.

• Experience in overseeing referral and authorization functions in a managed care environment.
• Working knowledge of Medi-Cal, DHCS, CMS, CCS, DMHC a must.
• Application level understanding of HIPAA, Privacy Act, and ERISA.
• Application level understanding of referral and authorization processes, standards, and requirements.

Physical Requirements:

• Occasional driving within County.
• Prolonged sitting and frequent walking.
• May be required to work evenings and/or weekends.