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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.

Manager Utilization Management

Location: Santa Clara, CA Additional Locations:
Job Number: 787129 Date posted: 07/02/2019
Description:
Develops, coordinates and manages the administrative and operational activities that are directly associated with the utilization  management of medical services provided to Kaiser members. Works independently; establishes priorities for staff.


Essential Functions:
- Chairs and Co-chairs local committees focused on creating, implementing and monitoring work plans to achieve UM targets and performance improvement. Provides expertise into target setting processes. Shares accountability with other medical center leadership for the daily monitoring of utilization indicators and performance, identification and escalation of problems, and initiation and evaluation of action plans for achieving medical center targets and improve the quality of care and services. Participates and provides UM expertise on local and regional committees, including UM Peer, UM Chiefs/Directors, Quality, TPMG, other departments and contracted/planned providers. Manages projects related to chart reviews.
- Conducts utilization data analysis (avoidable days, readmissions, UMAB, PRS reports, one-day stays, DRGs, LOS, PDRs, etc.) for trending and development of performance improvement initiatives. Partners with the UM Chief and KFH/TPMG local medical center leadership, to engage the following areas in the development and implementation of a comprehensive utilization management work plan to meet or exceed medical center targets: Physicians, managers across the continuum, and TPMG/KFH service leaders and managers. May include oversight of the coordination of KP members' care with leaders responsible for UM activities associated with alliance/contract hospitals and networks.
- Links with the Quality Department to ensure quality improvement, risk, and safety management activities are aligned with local UM initiatives.
- Identifies and incorporates (as appropriate) evidence-based best/successful practices (e.g. care paths, innovative discharge planning / case management models, etc.) into efforts to improve quality of care/service and reduce costs.
- Collaborates with interdisciplinary teams across the continuum of care including, but not limited to (HBS, TPMG Sub-specialty departments, Nursing, MSW, PT/OT, HH, Hospice, SNF, CCM, Behavioral Health, Rehabilitation, etc.). to ensure patient care is effectively provided, clinically appropriate, service oriented, safe and cost effective. Partners with TPMG to provide UM related education and training as needed.
- Ensures compliance with regulatory/accreditation (NCQA, MDQR, CMS, Medi-Cal, DMHC, DOL, JCAHO,etc.) requirements related to UM by partnering with other departments and facilitating workgroups in maintaining survey readiness.
- HR related activities (average 18 employees): Manages and resolves human resource, employee, department safety, and risk management issues. Responsible for all aspects of staff management including, hiring, development/training, performance reviews and terminations.
- Manages department budget and finances. Develops implements, and monitors departmental policies and procedures.
- Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees.

Basic Qualifications:
Experience


- Three (3) or more years of experience in management /leadership in a hospital or outpatient setting.


- Minimum three (3) years of previous experience in utilization management activities required.


Education


- Graduate of accredited school of nursing.


- BSN or BA in health care related field OR four (4) years of experience in a directly related field required.


License, Certification, Registration


- Current California RN licensure.


 


 


 


Additional Requirements:


- Knowledge of the Nurse Practice Act, JCAHO, NCQA, and other local, state, and federal regulations.


- Demonstrated skills in leading and facilitating the efforts of multidisciplinary groups.


- Demonstrated strong communication, problem-solving and analytical skills.


- Must be able to work in a Labor/Management Partnership environment.


 


 


Preferred Qualifications:


- Master's degree preferred.



 

Primary Location: California,Santa Clara,Santa Clara Hospital 700 Lawrence Express Wy. Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon - Fri Working Hours Start: 8:00 AM Working Hours End: 4:30 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: Continuity of Care Travel: No 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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