Kaiser Permanente Manager Utilization Management in Honolulu, Hawaii
Responsible for all aspects of compliance related to utilization Mgmt across, care coordination, & discharge planning in the Hawaii Region. Partner & coordinate w/ other care delivery teams in long term care, geriatrics, home health, primary care, & community based srvs, for different lines of business such as Medicare/Medicaid teams. Provide oversight, Mgmt, & supervision of the Authorizations & Referrals Mgmt. Ensures cost effective operation w/ maximum efficiency while maintaining high level of quality care & srv throughout Region. Ensure that the care delivery teams are evaluating all post discharge options to prevent admissions & readmissions to acute hospital. Manage the development, implementation & evaluation/improvement of effective utilization Mgmt & resource stewardship strategies ensuring compliance w/ external & internal regulatory bodies & standards. Knowledge of State & Federal regulatory & accreditation requirements: DHS, NCQA, & CMS. Assists w/ TJC preparedness. Supervises assigned staff. Serves as role model to front line staff.
Day to Day Operations: Directs the day-to-day operations for Regional Utilization Mgmt, case coordination, discharge planning. Plans, supervises, & evaluates work assignments. Ensures timeliness & appropriateness of review of cases. Directs & coordinates team efforts to optimize hospital days. Participates in utilization rounds for timely, appropriate medical treatment. Evaluates plan of care. Communicates discharges to Bed Control in tight bed situations. Manages patient complaints related to UM or discharge planning. Oversees denials, termination of benefits, & appeals processes. Directs programs that optimize patient/family &/or member satisfaction w/ care received in the KP & non-Kaiser facilities setting. Develops strategies for determining the most cost-effective, efficient levels of continuing patient care. Provides clinical leadership & support to patient care team.
Dept Performance Excellence: Supports Director w/ quality & performance criteria, policies & procedures, & srv standards for the utilization Mgmt operations. Leads, contributes, & provides technical leadership to highly visible, large, complex multi-dimensional analytical & clinical projects that identify & resolve utilization Mgmt issues of strategic importance to the Hawaii Region. Evaluates utilization reviews & determines program improvements. Implements modifications & improvements to existing programs as needed. Designs research plans for data gathering & analysis. Participates in interpreting analysis & developing action plans accordingly. Determines goals & priorities w/ Mgmt team sponsors. Ensure that action plans integrate well across other Depts in the continuum of care.
Authorizations & Referrals Mgmt: Coordinates w/ authorization & referral Mgmt team on outside referrals & coordination of care. Ensure that referrals are entered accurately & timely.
Strategic Planning & Implementation: Supports Director & collaborates w/ the key physician & administrative leaders to establish resource stewardship priorities & strategies for the Region. In collaboration w/ other key leaders, determine the strategic direction of the Dept. Plans & facilitates meetings. Makes formal presentations to various senior level audiences. Assists, as needed, in planning & coordinating w/ other teams & projects to maximize effectiveness. Produces or oversees development of written materials for senior executives & other key clients. Ensures that teams are executing on strategic plan effectively. Supports the Director on hardwiring performance improvement changes.
This job description is not all encompassing.
Minimum five (5) years of experience in clinical environment to include outpatient, acute, or post-acute care.
Minimum two (2) years of management experience.
- Bachelor's degree in health care administration, public administration, nursing, health services or business administration; OR four (4) years of related education and/or work experience.
License, Certification, Registration
Valid Hawaii RN license (must meet education requirement(s) for Hawaii State licensure) upon hire.
Current BLS for Healthcare Provider CPR or CPR/AED for the Professional Rescuer certification upon hire.
Knowledge and understanding of UM regulatory requirements.
Demonstrated knowledge of and skill in word processing, spreadsheet, and database PC applications.
Case management experience.
Master's degree in health care administration, public administration, nursing, health services or business administration, or related field.
Certified Community Health Nurse by the American Nurses Association (ANA).
Knowledge of health care information systems.
Budgeting and management skills in acute hospital setting.
TITLE: Manager Utilization Management
LOCATION: Honolulu, Hawaii
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, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.