Utilization Manager II - UM System Services - Corporate Offices (Hybrid) - FT - Days

Hourly Pay Range (Minimum - Midpoint - Maximum)

• The stated pay scale reflects the range as defined by the collective bargaining agreement between Sharp HealthCare and Sharp Professional Nurses Network, United Nurses Associations of California/Union of Health Care Professionals, NUHHCE, AFSME, AFL-CIO. Placement within the range is based on years of RN experience.
• Bachelor's Degree in Healthcare or a related field
• 3 Years Utilization Management or case management within a hospital or payer setting.
• 3 Years acute care nursing experience.
• 2 Years recent pertinent clinical experience as defined by the CBA.
• California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED
• Bachelor's Degree in Nursing
• Experience with Milliman Care Guidelines (MCG)
• Experience and understanding of federal and state regulations governing utilization management
• Accredited Case Manager (ACM) - American Case Management Association (ACMA) -PREFERRED
• Certified Case Manager (CCM) - Commission for Case Manager Certification -PREFERRED
• Collaboration and teamwork Represent management (as requested) at system and site level meetings. Perform initial and concurrent review on intent to bed or bedded patients. Works collaboratively with system emergency departments (ED), attending physicians as well as the physician advisor. Identifies and escalates cases not meeting criteria for admission or concurrent stay. Works proactively to identify solutions when these cases are identified. Advises the physician advisor of these cases and works to mitigate denials. Reviews hospitalized patients with the Physician Advisor and/or facility UR chairperson as requested or required by plan/group/payer. Identifies and reports upon as appropriate any emerging variances or trends counter to the division and organizational objectives. Maintain records and statistics as required, i.e. - bed days, discharges, re-admissions, diagnoses. Ensures accurate and timely completion of all documentation requirements. Coordinates transfer of 'out-of-network' patients, when indicated. Maintain confidentiality of all patient and Utilization Management information. Participate in ICM Care Conferences as requested. Work collaboratively with other members of the health care team as well as the respective medical groups to facilitate the utilization management process. Identify and refers situations needing immediate intervention to UR Manager, Physician Advisor, as appropriate. Participate in system or site-level utilization review activities and projects as needed. Maintain a log and report of all high risk, long stay patients and/or otherwise outlier patients.
• Communication Facilitates information sharing and project coordination where appropriate between teams and facilities. Develops collaborative relationships with nursing departments, payers, hospitals, and Physicians. Consistently models behavior, service delivery, and communication in a manner so as to distinguish the Centralized UR as an ever-role model for efficiency, superior customer service and problem solving. Uses communication strategies with individuals and groups that result in achievement of intended outcomes and always positive relationships.
• Maintain a high degree of professionalism: Demonstrate the ability to make decisions, take appropriate accountability with action and follow tasks through to completion. Recognize and analyze the implications of new situations and develops workable solutions to maintain productivity and morale. Act as a best-practice role model in demonstrating the customer service standards of the organization. Demonstrate a commitment to personal growth and development by participating in external activities related to professional goals. Respond cooperatively to managers and staff members in other departments to promote teamwork. Attend departmental meetings as appropriate and contributes ideas for improving efficiency, productivity and patient satisfaction.
• Professional development Drives change at the individual contributor level to improve overall process and team performance. Identifies and seeks out opportunities to grow individual competency and skillset in the area of utilization review, integrated care management and transition planning. Seeks out opportunities to take on department projects or identifies performance improvement activities. Maintain a high-quality work product. Remains ever aware of regulations, laws, practices, standards and other influencers to care management practice.
• Proficiency with information systems and computer programs such as word, excel, etc.
• Advanced clinical skills in area of expertise.
• Proficient knowledge and understanding of utilization management.
• Demonstrated understanding and abilities for superior service management and relationship advancement skills.
• Demonstrated understanding and competency with evidenced-based guidelines.
• Self-directed and demonstrates ability to prioritize.
• Demonstrated ability to remain flexible in rapid change environment and current health care dynamic climate.
• Work collaboratively with interdisciplinary team.
• Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class