Job Description

Imperial Health Holdings is hiring a Utilization Manager, RN. Must be clinical

People are the most important asset of Imperial , for this reason the differences and plurality of people, equality of opportunities, non-discrimination and inclusion in the workplace are priority and strategic factors in the Organization. Imperial maintains a strong will to promote Diversity, Equity, and Inclusion, through inclusive leadership as a lever change and business sustainability.

Imperial Health Plan of California, Inc., is licensed by the California Department of Managed Health Care as a health care service plan in accordance with the Knox-Keene Act to provide Medicare Advantage covered services, including a Medicare Advantage Prescription Drug plan, and a Chronic Condition Special needs plan over numerous counties in California. Through its affiliates, Imperial Insurance Companies, Inc., and Imperial Health Plan of the Southwest, Inc., it also offers individual marketplace covered services in Texas, Utah, Nevada and Arizona.

Responsibilities

• Assigns work schedules, delegates reviews, provides direction on review priorities, meets the demands of internal and external partners, and ensures staff achieve performance goals and adherence to company policies.
• Ensures UM team documents on the medical management system timely manner, all supporting clinical information, outreach attempts, and criteria used to make a determination.
• Monitors, tracks, and reports any inappropriate referral patterns to the UM Medical Director and Director of UM.
• Participate in inpatient and OP huddles to review inpatient census including Inpatient CMs and CMO, to discuss cases and discuss barriers of discharge planning.
• Oversight of the UM Compliance team.
• Prepare and participate in UM internal and external audits.
• Develop and revise UM program, workplans, and policies and procedures.
• Prepare and update quarterly, semi-annually, and annually UM workplans.
• Participate in UMC meetings and other meetings as needed.
• Prepare and submit compliance reports related to UM activities.
• Oversight of outside vendors that are tracked by Lead UM Coordinator.
• Assures all performance evaluations are conducted timely.
• Correspond promptly to health plan requests that are related to UM activities.
• Monitors staff attendance, production and performance goals.
• Works closely with other departments to achieve assigned goals.
• Facilitates an atmosphere of interactive management and the development of collegial relationships among personnel and others.

Qualifications

Bachelor's Degree in Health Care or related field

Required Skills

At least 5 years of management experience in a Medical Group, MSO, Hospital, or Health Plan setting

At least 5 years of experience in UM/Managed Care setting

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