Utilization Review Manager
Join a company that was ranked among the TOP 25 companies to work for in Los Angeles!
Join AltaMed’s team of multicultural health care professionals in serving more than 150,000 families a year. Our integrated system emphasizes prevention and healthy living to reduce health care disparities in multi-ethnic communities and avoid unnecessary trips to the emergency room or other more costly forms of care.
AltaMed is the largest independent Federally Qualified Community Health Center in the U.S., with more than 930,000 annual patient visits. Our culturally competent physicians and health care professionals provide integrated primary care services, senior care programs, and health and human services at 43 accredited sites in Los Angeles and Orange Counties. Established in 1970, AltaMed is proud to be a national model for the delivery of quality, patient centered care to underserved communities. We currently have an excellent opportunity for the following:
Utilization Review Manager
Full-Time/Regular, Req #178
Under the direction of the Director, Healthcare Services and QM, the selected candidate will oversee and manage the day-to-day operations of the Utilization Management Department and health plan delegated activities.
• Work collaboratively to evaluate and monitor medical appropriateness determinations and care coordination activities.
• Develop/implement strategic plans that positively impact cost containment and patient outcomes.
• Oversee referrals/authorizations related to coordinating outpatient/inpatient clinical care.
• Ensure compliance with regulatory requirements and application of clinical decision support criteria for care management activities as required by federal, state and other regulatory and accreditation agencies.
• Perform audits of utilization review referral activity.
• Oversee utilization review activities of delegated entities (IPA, Health Plans, etc.).
• Direct and educate staff on managed care utilization review operating systems.
• Monitor utilization review activities to ensure compliance with policies and procedures.
• Interact with delegated entities and Medical Management staff to determine potential case management needs/care coordination.
• Ensure quality standards are met while providing appropriate, cost effective care.
• Assist in coordinating activities between Medical Management, IPA and contracted Health Plans.
• Ensure non-clinical staff has direct access to licensed health professionals during the utilization review process and related activities.
• Develop health plan work plans to include SMART goals, interventions and measurable outcomes.
• Complete corrective action plans and create, implement and monitor changes and reporting outcomes.
• Develop policy, procedures and workflows to measure outcomes.
• Use data analysis and process improvement tools to monitor and improve performance.
• Help ensure a state of continual readiness for Delegation Oversight Audits.
• Adhere to AltaMed Heath Services’ HIPAA Compliance Plan and the Privacy Standards Confidentiality Agreement.
• Bachelor’s degree in Nursing or related healthcare field preferred.
• Minimum 5 years’ hospital or insurance industry experience in managed care with at least 1+ year(s) in a supervisory capacity or equivalent.
• Experience managing remote employees preferred.
• Knowledge of state and federal regulations.
• Experience with EHR systems highly desirable.
• Computer hardware and software proficiency.
• Effective interpersonal and verbal/written communications skills.
• Ability to work collaboratively with all levels of management, particularly Medical Management and network management team.
AltaMed offers extensive opportunities for professional development, as well as competitive salaries and excellent benefits. Our team members enjoy medical, dental and vision plans, retirement plan with matching employer contributions, tuition reimbursement, continuing education programs, and much more. We invite you to join us in making a difference in our communities and in the lives of others.
For immediate consideration, please apply online at AltaMed.org.
AltaMed is fully committed to Equal Employment Opportunity and to attracting, retaining, developing, and promoting the most qualified employees without regard to their race, gender, color, religion, age, or any other characteristic prohibited by state or local law. We are dedicated to providing a work environment free from discrimination and harassment, and where employees are treated with respect and dignity.
View a full list of open positions and apply online at AltaMed.org.
AltaMed is accredited by The Joint Commission. EOE M/F/D/V