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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 of Utilization Management

Location: Fontana, CA Additional Locations:
Job Number: 700439 Date posted: 07/12/2018
Description:
Develops, manages and directs the Utilization Management programs in a Service Area or a Medical Center. Develops and manages programs that emphasize appropriate admissions as well as concurrent and retrospective review of care. May also be responsible for other integrated functions such as Discharge Planning, Case Management program, Outside Utilization Review program, Transportation coordination and Extended Care Coordination to promote a centralized, coordinated, interdisciplinary process in the continuum of care.


Essential Functions:
- Provides overall direction, design, development implementation and monitoring of utilization programs to meet the Service Area's or Medical Center's utilization goals while maintaining customer satisfaction.
- Acts as a resource to the medical staff, administrative staff, divisional, SCPMG, TPMG and external regulatory agencies in all issues relating to utilization management within the Service Area or Medical Center.
- Oversees outside medical services based on Health Plan benefit guidelines and medical necessity.
- Analyzes and reports significant utilization trends, patterns, and impact to appropriate departmental and medical staff committees.
- May direct the operations of outside referrals/transportation services.
- May serve as contract liaison for the Service Area or Medical Center on issues pertaining to new or existing contracts with outside vendors.
- Develops, monitors and controls department's budgets.
- Assures compliance with Federal, State, TJC, NCQA, other regulatory agencies and internal standards and requirements.
- Hires, coaches, trains and disciplines staff to ensure smooth operations in utilization management.
- Also facilitates educational training for medical staff on issues related to utilization management.

Basic Qualifications:
Experience
- Minimum three (3) years of experience in directing utilization management and discharge planning in an acute care setting.
Education
- BSN or bachelor's degree in health care related field such as management, health services administration.
License, Certification, Registration
- Current California RN license.
 
Additional Requirements:
- Demonstrated knowledge of operations and healthcare management; TJC, Title XXII, Medicare, Medi-Cal and other local, state and federal regulations.
- Knowledge of managed care operations.
- Demonstrated interpersonal, negotiation, and leadership skills.
- Effective oral and written communication skills.
- Must be able to work in a Labor/Management Partnership environment.
 


Preferred Qualifications:
- Master's degree in a related field such as nursing, business or health services administration preferred.

Primary Location: California,Fontana,Fontana Medical Center (replacement) 9961 Sierra A Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri, Working Hours Start: 8:00 AM Working Hours End: 5:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: Salaried, Non-Union, Exempt Job Level: Manager with Direct Reports Job Category: QA / UR / Case Management Department: Utilization Travel: Yes, 50 % of the Time

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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