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Kaiser Permanente Careers

Quality Assurance, UR & Case Management

Passion + Vision + Integrity = Excellence

Ensure consistency and the highest ethical standards across our entire organization. Our quality assurance team drives ongoing improvement by fostering an environment of support, providing technical and specialized consultative services, and inspiring ongoing excellence.

Director, Regional Utilization Management

Location: Aurora, CO Additional Locations:
Job Number: 808696 Date posted: 07/18/2019
Manages the overall, regionwide utilization management function ensuring the accurate and timely prior authorization of designated healthcare services. Oversees the concurrent, discharge planning and retrospective review activities for the Colorado region. Manages utilization review staff.

Essential Responsibilities:
  • Manages the administrative and operational functions of the regional utilization management department. Responsible for the planning and decision-making related to utilization review. Develops and implements departmental policies and procedures. Develops, implements, and maintains utilization management programs to facilitate the use of appropriate medical resources by health plan members/patients.
  • Identifies and monitors services with potential for undesirable variation to ensure accurate and consistent application of benefits and clinical guidelines or criteria. Develops and reviews medical necessity criteria and utilization management practices including a formal process of monitoring and evaluating the necessity, appropriateness, efficiency, effectiveness, and safety of medical services to achieve favorable healthcare outcomes. Reviews analyses of activities, costs, operations and forecast data to determine progress toward utilization management goals and objectives. Compiles and reviews multiple reports for statistical and financial tracking to identify utilization trends and make recommendations to management and to ensure inter-rater reliability of staff performance.
  • Ensures compliance with national and state regulatory/accreditation requirements related to utilization management by partnering with other departments and facilitating workgroups in maintaining survey readiness to ensure that all annual requirements are met. Engages in monthly/quarterly/annual/triennial internal and external utilization management audits and surveys and delegation oversight audits.
  • Manages and oversees the utilization review management training and education program for Utilization Review leaders and staff across the region. Ensures post-course evaluation tools and other materials are developed. Manages training and education schedules.
  • Manages case managers including hiring, training, performance evaluations and terminations. Ensures tools and technology are created and improved to perform activities and ensure timely and appropriate documentation for accurate data capture and reporting.
  • Facilitates on-going communication and manages relationships among utilization management staff, internal providers care management peers and leaders, and external/contracted providers.  Manages performance and issues with internal and external representatives regarding Union Issues, as necessary.
  • Basic Qualifications:
  • Minimum eight (8) years clinical and medical utilization/review experience.
  • Minimum five (5) years supervisory/management experience.
  • Education
  • Bachelor's degree in related field OR four (4) years of experience in a directly related field.
  • High School Diploma or General Education Development (GED) required
  • License, Certification, Registration
  • N/A

  • Additional Requirements:
  • Thorough knowledge of utilization management and clinical practice.
  • Familiarity with Medicare and Medicaid managed care practices and policies, CHIP and SCHIP.
  • Knowledge of regulatory/accreditation requirements (NCQA, DMHC, DHCS, CMS, Medi-Cal Plan Partners, Special Needs Plan (SNP)).

  • Preferred Qualifications:
  • Recent clinical experience in a hospital setting preferred.
  • Bachelor's degree in nursing preferred.
  • Case Management Certification preferred.
  • CO RN license preferred.
  • Primary Location: Colorado,Aurora,Waterpark II 2530 S. Parker Rd. Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon-Fri Working Hours Start: 8:00 AM Working Hours End: 4:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: Salaried, Non-Union, Exempt Job Level: Director/Senior Director Job Category: QA / UR / Case Management Department: Resource Stewardship Utilization Management Travel: Yes, 10 % of the Time Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.

    External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.

    About QA, Ur & Case Management Careers

    Careers In QA, Ur & Case Management

    As an organization, we are committed to delivering the same exemplary care no matter who you are, where you are, or what your needs. But how are those standards defined, measured, and assessed? That's where our quality assurance team comes in. Implementing the action plans and initiatives that will drive successful practices, you'll work across the organization to foster the necessary education, communication, and innovation that will enable us to operate as one KP — with our mission and goals in complete alignment.

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