Director, Utilization Management Job at Alameda Health System, Oakland, CA

V1p2NGh2OUl0UHVyNkRWUCsrVkRUZGh2S3c9PQ==
  • Alameda Health System
  • Oakland, CA

Job Description

Job Description

Summary

\n

\n

    \n\t
  • 100% employer health plan for employees and their eligible dependents
  • \n\t
  • Unique benefit offerings that are partially or 100% employer-paid
  • \n\t
  • Rich and varied retirement plans and the ability to participate in multiple plans.
  • \n\t
  • Generous paid time off plans
  • \n
\n\n

 

\n\n

Role Overview:

\n\n

Alameda Health System is hiring! The Director of Utilization Management holds a critical role encompassing operational oversight, strategic planning, compliance, and collaboration. Their responsibilities span from managing admissions to ensuring clean claims, identifying trends, and optimizing resource utilization. This role supports patient care coordination, fosters physician collaboration, and aligns with organizational objectives while adapting to ad hoc duties as needed. In essence, they orchestrate efficient utilization management to deliver high-quality patient care.

\n\n

 

\n\n

DUTIES & ESSENTIAL JOB FUNCTIONS : NOTE: Following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification. 

\n\n
    \n\t
  • Lead and manage a team of utilization review professionals providing guidance, training, and performance evaluations. 
  • \n\t
  • Monitor and evaluate the utilization of healthcare services, including appropriateness, efficiency, and medical necessity of treatments and procedures. 
  • \n\t
  • Analyze data and generate reports on utilization trends, outcomes and quality indicators to support decision-making and process improvement initiatives. Reports to appropriate committees. 
  • \n\t
  • Manage quality of performance criteria, policies and procedures, and service standards for the utilization management operations. Evaluate utilization reviews and determine program improvements.  
  • \n\t
  • Develop and implement utilization review policies and procedures in accordance with industry standards and regulatory requirements.  
  • \n\t
  • Direct and coordinate data gathering and record keeping legally required by federal and state agencies, the Joint Commission, and hospital policies; participates in the risk mitigation, process of implementing new or revised processes, and projects 
  • \n\t
  • Foster effective communication and collaboration with internal departments, external agencies, and insurance providers to facilitate the utilization review process. 
  • \n\t
  • Participate in interdisciplinary committees and meetings to contribute to the development and implementation of quality improvement initiatives.  
  • \n\t
  • Oversees the secondary review process; actively appeals denied cases when necessary and assists physicians with appeals. Maintains minimal denial rates by Medicare, MediCal, private and contracted payers through appropriate direction of utilization practices; assists physicians and hospital personnel in understanding UM matters. 
  • \n\t
  • Perform all other duties as assigned. 
  • \n\t
  • Prepares cost analysis reports and other data needed for the preparation of the departmental budget. 
  • \n\t
  • Provides in-house educational programs as needed for both staff and physicians. 
  • \n\t
  • Responsible for the recruitment, orientation, evaluation, counseling and disciplinary action of UM and administrative staff. 
  • \n\t
  • Serves as a content expert to staff and internal departments and external partners; networks with other hospitals, nursing organizations, and professional organizations to keep abreast of changes within the profession.
  • \n
\n\n

MINIMUM QUALIFICATIONS :

\n\n

Required Education: Bachelor’s degree in Nursing

\n\n

Preferred Education: Master’s degree in Nursing 

\n\n

Required Experience: Three years of utilization review experience. Health insurance company and/or acute care hospital, post-acute and psych; three years of InterQual and/or MCG. Strong clinical nursing background.

\n\n

Required Licenses/Certifications: Valid license to practice as a Registered Nurse in the State of California.

\n\n

Preferred Licenses/Certifications: UM / CM certifications

\n \n
Highland General Hospital
SYS Utilization Management
Full Time
Day
Nursing
FTE: 1

Job Tags

Full time,

Similar Jobs

AM Pierce and Associates

Software Developer Job at AM Pierce and Associates

 ...highly experienced and skilled Software Developer. Salary: The...  ...research, design, development, testing, and manufacturing operations....  ...software matters, provide real-time support for problem assessment...  ...location, date of hire, Full or Part-time status, and the... 

Detroit Staffing

Administrative Assistant, Curatorial Job at Detroit Staffing

 ...Compile and submit information regarding auxiliary and events for website and social media posts to Marketing and Communication. Apply DIA values to interactions to support a culture of belonging among internal and external stakeholders. Perform other duties as... 

HHS

Executive Chef - Relocation Assistance Available Job at HHS

Job Description Build a well-trained and motivated team that produces high-quality food while adhering to safety, sanitation, and service principles Provide leadership that supports a team environment that fosters morale, passion, quality, and respect Develop...

CyberCoders

Senior Fullstack Engineer Job at CyberCoders

 ...interactive, consumer-friendly learning experiences. Stack & Focus: React Native, TypeScript, JavaScript, Cloudflare Workers, GCP or AWS (Some light Python as we'll be growing with this over the next few months) Requirements: ~8+ years of fullstack engineering... 

State of Oregon

Administrative Specialist 1 NICS Act Record Improvement Program (NARIP) Job at State of Oregon

 ...Administrative Specialist 1 NICS Act Record Improvement Program (NARIP) The Oregon State Police in Salem, Oregon is hiring for one (1) Full-Time, Limited-Duration Administrative Specialist 1 NICS Act Record Improvement Program position. This is an in-office position...